Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ODI iq1 <br /> OWNER/OPERATOR /� <br /> 1 p_GI, 1�rC.�� CHECK If BILLING ADDRESS <br /> FACILITY NAME Wl 1 1 <br /> SITE ADDRESS `�?t� 1�� S �!-[_Q , �� I ( FL <br /> _tret Nber Direction ,� Street Name Ctt �ry Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c ) -O-D>-F) <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) Q[ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORQr l ��� <br /> V1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME E# EXT. <br /> C` q,5 -Q U53 a <br /> HOME Or MAILING ADDRESS3 I f�Q (� I k-►� CJ <br /> FAX# <br /> "I u U V V ( ) <br /> CITY UA`'��I/yry�/�IJ STATE 1 ZIP c52)up <br /> BILLING A`�CKN�JO'�WILIEDDGEMENT: 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, Standard , AT and FED AL laws. <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY I 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: M I+r L+10 �,5{ <br /> ` v P� <br /> COMMENTS: elG �tN✓T�S Re'.'e I pgl}biGf ��1d�[s►� l�I`eollh, <br /> OCT 16 2016 <br /> SgENVIR QUI N COU <br /> Ll— NTy <br /> ACCEPTED BY: e11 EMPLOYEE#: pE <br /> T' <br /> ASSIGNED TO: tl EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: It(/., <br /> Fee Amount: -� DO Amount Paid �q ^� Payment Date / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />