Laserfiche WebLink
SAN JOAQUIT— ` OUNTY ENVIRONMENTAL HEALTIY DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V�/ <br /> fi <br /> SITE ADDRESS y� 1 l N� 175'3 d 1.1 <br /> 2L{2 Street Number Direction\ Street Name I,`— Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2CopZ Street Number Street Name <br /> CITY � STATE ZIP <br /> �>^e,� op <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION# <br /> (925) 788 -55 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� CHECK if BILLING ADDRESS E] <br /> BUSINEsa NAME lY PHONE# EXT. <br /> WS 025) 70P)'S5-30 <br /> HOME or MAILING ADDRESS FAX# <br /> 2 r- I/� ( ) <br /> CITY „ STATE ZIP <br /> 51 3 <br /> BILLING ACKNOWLEDGEMENT: 1, <br /> G ;/[: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 /> 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: 12- <br /> PROPERTY/BUSINESS OWNER�Y OPERA T MANAGER ❑ 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: - <br /> COMMENTS: O/l& awc 6C PtAA/ wit., vr— .5ozw?ow Ar LA,17A O V E D <br /> UEL 14 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 5HFAI TH nFPARTMENT <br /> ACCEPTED BY: C EMPLOYEE#: DATE: <br /> ASSIGNED TO: J v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P 1 E: <br /> Fee Amount: �2,? Amount Paid q0 O Payment Date 2 y (J S <br /> Payment Type t 7 Invoice# Check# 1 (J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />