Laserfiche WebLink
SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNE /OPERATOR <br /> CHECK If BILLING ADDRESS <br /> C <br /> FACILITY NAME -0{T I us D 1 \ ( 1 <br /> SITE ADDRESS !I /�G�I r C -� jX'k k-v <br /> 0 , � ree Number Direction �" Street Name �./ Ci ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (gym) J33 5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( Y As <br /> l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ����� / > � CHECK if BILLING ADDRES <br /> BUSINESS NAME ) ) (J G� PHONE# / _ EXT. <br /> F I <br /> 23 <br /> HOME or MAILING ADDRESS FAX# <br /> Z � AI ( ) <br /> CITY r j STATE /A ZIP C v <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 /> also certify that I have prepared this applicationa d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STAT nd DERAL laws. <br /> r / _ <br /> APPLICANT'S SIGNATURE: __: / DATE: Z j <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN is s riot 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the S 'provided to me or <br /> my representative. Q� <br /> TYPE OF SERVICE REQUESTED: ! <br /> COMMENTS: n (� MAY 2 <br /> `'� "CkA9 (3 T O VJ(1 SAN JOAQUIN COUNTY <br /> I STN DEPARTMENT <br /> ACCEPTED BY: In EMPLOYEE#: DATE: —? <br /> ASSIGNED TO: EMPLOYEE#: DATE' ' <br /> Date Service Complete (if already completed): SERVICE CODE: R I PIE: G> <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />