Laserfiche WebLink
I <br /> E <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Buslness or Property FACILITY ID# _ SERVICE REQUEST# <br /> OWNER I OPERATOR ] <br /> ���,^ CHECK If81LLWGADDRESS <br /> � I <br /> Jt ` l <br /> FACILITY NAME <br /> SITE ADDRESS <br /> - Street Number Dlre n "' �Stre Name Clt ZI Code <br /> HOME <br /> or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CCSL STATE ZIP q <br /> Ottl� 7 <br /> PHONE#1E tT APN# LAND USE APPLICATION# <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTORp . <br /> If BILLING ADDRESS {{ <br /> UI V1 Gtr �- U 0 J <br /> BUSINESS(NAME &r-'" n PHONE 5 0T <br /> HOME Or MAILING ADDRESS Y ` • Q r_ y� <br /> z YYIar� s rQ F # ) S2 o �Q 7 <br /> CITY ( STATE Cu zip I? <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 i <br /> or 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 /> r <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Lp OTHER AUTHORIZED AGENT❑ <br /> 3 <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 and at the same time it is i <br /> provided to me or my representative. P <br /> TYPEOFSERVICE REQUESTED: �� •o <br /> COMMENTS: A`4 Y ® 1, <br /> SAN J © ZQ,S 39 <br /> "I' ty NM COVN <br /> HpEpgR M t �' <br /> ACCEPTED BY: �\ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: `52� Amount Paid / U Payment Date <br /> Payment Type Invoice# Check# /QG� Received By i , <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br /> S <br />