Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property \ � _ FACILITY ID# ©SERVICE REQUEST# <br /> ��e�cicph T�5\-OfGti S0t)wvq� <br /> u t.�-t r! V�V <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME v <br /> SITE ADDRESS ori _,qtr �� Y lr. ' ( > <br /> ( ( <br /> Street Number Direction `�. Street Name ` v l- <br /> *==0 <br /> ') <br /> ✓� Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> &�C' �) o - Ii r O _ <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> SIV�^ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME i PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY n STAT ZIP <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 /> I also certify that I have prepared this application�J-i d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATF"and.F��EDERAL laws. <br /> APPLICANT'S SIGNATURE L;;� , � DATE:a (o: + I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 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. POMENT <br /> TYPE OF SERVICE REQUESTED: GS�til�d �� <br /> RECEIVED <br /> COMMENTS: <br /> �� AUG 0 1 2019 <br /> O��� <br /> P SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ' <br /> ASSIGNED TO: IJP EMPLOYEE#: ✓ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount:1 Amount Paid L s'Z Payment Date <br /> Payment Type Invoice# pbeck# L O b l] 2_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> W10 ki?X41 Li <br />