Laserfiche WebLink
I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# j <br /> 1 <br /> men. ma,y <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESs <br /> Street Number• D1r4'—lon Streat ame Cit Z Code <br /> HOME'or MAILING ADDRESS (If Different from Site Address) <br /> `'( fflStreet Number Street Name <br /> CI Cr, STATE Zip 6- <br /> PHONE#1 E-77 APN# LAND USE APPLICATION# <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> ,t !, �—k v0� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �� � � PHONE l 2 r 1 <br /> HOME or MAILING ADDRESS F # 5 7 7 <br /> CITY C STATE ZIP I? A <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 <br /> or activity will be billed to me or my business as identified on this form. {a <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. t I <br /> APPLICANT'S SIGNATURE: DATE: 6 <br /> �y 1 <br /> PROPERTY/BUSLNESs OWNER❑ OPERATOR/MANAGER Lp 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 � <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available-ka t the same time it is <br /> provided to me or my representative. "'$;, <br /> TYPE OF SERVICE REQUESTED: l <br /> COMMENTS: MAY ' 0 2019 <br /> SANjOAQU <br /> NEAN H DIN <br /> EpAR MACOUNN <br /> Nr <br /> 1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> V <br /> Date Service Completed (If already,4ornplated): SeRvlce CODE: P 1 E: i <br /> s <br /> Fee Amount: S 2-- <br /> Amount PaPayment Date S� I <br /> Payment Type Invoice# Check# 9�/% � Rece ved By: - <br /> i <br /> i <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 7/2 003 <br />