Laserfiche WebLink
F SANJOAQUINUOUNTYENVIRONMENTAL HEALl-H]JEFAltltvirIN1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S e oo 5 071q <br /> t <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESSjkbeq <br /> ti <br /> C) 7D,y0 <br /> J Street r rection reet Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> I CITY ST TEZIP <br /> i <br /> PHONE#I LAND USE APPLICATION# <br /> PHONE#2 Ex-r. 60S DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR! SERVICE REQUESTOR <br /> �. REQUESTO w <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME . ` tJ P}{ONE#) Err. <br /> HOME or MAILING ADDRESS FAx# <br /> (DM <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEMENT: 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,Standa ds, STATE and FEDERAL laws. � <br /> APPLICANT'S SIGNATURE: DATE: � � DI <br /> l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT. <br /> GENT C���OIC~� <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: t ' r <br /> I <br /> COMMENTS: REC61VED <br /> �� ���� 5�,�•��.� ������� ���� MAY � 4 2007 <br /> i ( /_•�� c>A ` SAN JOARONMI AL <br /> ACCEPTED BY: EMPLOYEE#: z DATE <br /> ASSIGNED TO: EMPLOYEE#: ./ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:;a <br /> Fee Amount: 0 rl Amount Paid lk `��� �,� Payment Date �(2t(0:7 <br /> Payment Type Invoice# Check# Received By: � <br /> r <br /> EHD 48-02-025 SR FOFW(Golden Rod) <br /> REVISED 11/17/2003 <br />