Laserfiche WebLink
SAN JOAQI�N COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 0 a(J t G, \0I J CHECK If BILLING ADDRESS� <br /> FACILI NAME \ CdXt 1 <br /> SITE ADDRESS 234 Z t I M Cly Y� ,S 1 .S TU9)�z <br /> Street Number Direction Street Name CI Zr CodeJ� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> O - Street Number Street Nei <br /> CIN „ �/ j�•)1/) STATE ZIP e? <br /> (ij�l/r 1 GVH % � <br /> PHONE#f En' (o <br /> APN# LAND USE APPLICATION# <br /> cz�l 16 23 3 z 3 z , 553[�00 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / I <br /> I.O a ,^dr./�l R- 01 <br /> Vl/0 CHECK If BILLING ADDRESS <br /> BUSINESS NAME l` I/IY 1(.If (� VV (/fir✓ lJ PHONE# ExT. <br /> e5 tJ CAC ('<-)c.1 c Q �<'c - 6 Z S <br /> HOME or MAILING sv w ADDRESS'l5 Fax# <br /> o ^) <br /> CITY S J STATE Cr'\ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentofsame, " <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 F�laws. �7 <br /> APPLICANT'S SIGNATURE: ,� ( r DATE: <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN Aof the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 provldbd t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: , <br /> /; �� SAN <br /> lif(��2 � <br /> ACCEPTED BY: EMPLOYEE#: DATE: Li. <br /> ASSIGNED TO: EMPLOYEE DATE: b -'0-1-1 <br /> Date Service Complete (if already completed): SERVICE CODE: / PIE: V r� <br /> Fee Amount: Amount P / Payment Date <br /> / r <br /> Payment Type Invoice# Check# Rece ed By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />