Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICE REQUEST# <br /> Ue y s c'a\-4 <br /> lw=op, <br /> ERA 1 I <br /> (�V `^„O,^�/ CHECK if BILLING ADDRESS O <br /> FACILITY N YYY /lll`YYY���r 111 / 1(�j �� O <br /> SITE AD/DREpU <br /> V �Slmmber Direction �`� Street Name '`--�� " � Code <br /> HOME Or MAILING A S (If Diff nt from Site dress)�\y/yO /�`J <br /> J 1 V Street Number Street Name <br /> CITY $ ZIP <br /> Y / <br /> PHyEl#1 EXT. APN# LAND USE APPLICATION# <br /> tNE 2 -`xT• BOS DISTRICT JLOCATION CODE <br /> ll/% )CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR'T <br /> r\� Y_ rT1/1 CHECK If BILLING ADDRESS <br /> B (NESS NA E � a If I en'ns <br /> Y t VY p xT. <br /> HOME or MAILING ADDRESS-/ FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE and FEDERAL laws, <br /> APPLICANT'S SIGNATURE:;,? C(, h�C�( DATE: l I <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asse >.ipin <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It I I or <br /> my representative. RECEIV <br /> TYPE OF SERVICE REQUESTED: o <br /> COMMENTS: <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: VI / n EMPLOYEE#: � DATE: 5 <br /> ASSIGNED TO: j�L Ir I(/\Q I EMPLOYEE#: DATE: S//-Gd-G / <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: )IW <br /> Fee Amount: /G5 A0 Amount Paid �� �— Payment Date / li <br /> Payment Type Imo✓ Invoice# Chgcit# 3 ZL�(�(o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />