Laserfiche WebLink
Pr- df�ns2-0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#//^^ SERVICE REQUEST# <br /> OVtVNER/OPERATORCHECK� I�, l // J <br /> FACILITY NAME C► CHECK If BILLING ADDRESS <br /> / , tC 111 <br /> ��7 <br /> S <br /> ITEDDRESS ' <br /> 2 5 ' 40eStreet Number Direction t No <br /> HOME or MAILING ADDRESS (If Different from Site Address) Vy <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (2tq) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> - REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> USINESS NAME \ ' �� PHONE# EXT. <br /> c�Lv <br /> HOME or MAILING ADDRESS FAX# <br /> �44 <br /> ( ) <br /> CITY STATE ZIP <br /> 7 <br /> BILLfNG A,CKNO' tfLEDGEIIAENT: 1, 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 applicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE:- !1421 Z/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ f ,•�i^ <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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Food (WcwiWlon RECEIVED <br /> COMMENTS: S E P 0'2 2 016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /� C �'l C,{1 ` EMPLOYEE#: DATE: / <br /> ASSIGNED TO: EMPLOYEE#: DATE: Z tf <br /> Date Service Completed (if already completed): SERVICE CODE: J6 O ( P/E: /i 7 <br /> Fee Amount: Amount Paid ;? ° Payment Date v <br /> Payment Type , ;� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />