Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of jBusiness or Property FACILITY ID# SERVICE REQUEST# <br /> Kf0o�A 2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> `IS \I ` Street Number I Direction Street Name Ciy Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> MOt'-fi 1A '01 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (tea 38�-- `�X20 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST Rn\ <br /> t,M A L J/ N A CHECK If BILLING ADDRESS El <br /> BUSINESS NAME r� n PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY T STATE `1 <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED AL laws. <br /> APPLICANT'S SIGNATURE: yc v �Q 11 DATE: x <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to me Or <br /> my representative. �REC ne�",,P YMEN <br /> y� <br /> TYPE OF SERVICE REQUESTED: 1 N <br /> COMMENTS: NOV L 1 201 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1_ I 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: i�_ 2'-1 <br /> Date Service Completed (if already completed): SERVICE CODE: 7.7 P/E: ((�j <br /> Fee Amount: Amount Paid Payment Date L, u <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />