Laserfiche WebLink
SANDAQUIN Cotri�TY ENVIVONMHENTAL11EALI auEr tiIVIrl\1 <br /> .J t <br /> SERVICE REQUEST <br /> ----F���' SERVICE RE4UES7# <br /> Type of Business or4Property FACILITY 1D# <br /> O NER 1 OPERATOR c - CHECK if BiLLIN�5SO <br /> /L! /OLa � <br /> FACILITY NAME <br /> / D <br /> SITE ADDRESS 20963i <br /> Street Number Direction <br /> Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> O?qo j5. Street Number Street Name <br /> CITY STATE zlP?OZ /P { <br /> S` - LAND USE APPLICATION# ` i <br /> PHONE#1 E"7 APN# <br /> PHONE#T ExT B0S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EREQUtESTR CHECK If BILLINGADDRtES3C7 E.T. <br /> PHONE# 7/ 'Jm/ ` <br /> HOME Or MAILING ADDRESS ^SrFNC# <br /> STATE ZIP <br /> CITY <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,5,TATE and FERE laws. <br /> .�LAPPLICANT'S SIGNATURE: DATE: > � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT..[] <br /> If APPLICANT is not the BiLLINGPARTI 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: 11116114W_ �{ W".9� 7 [J�- Z Pel fv 1rd `,ql?r-b 610 0-2 PAV l91a <br /> RECEIVED <br /> MAY Y 8 2006 <br /> 7/1191�16 rP..�� ,a W'° SAN JOAQUIN C <br /> r (Zee►' 3� Qu Ty <br /> IM <br /> ACCEPTED BY: EMPLOYEE#: MT <br /> ASSIGNED TO: EMPLOYEE#: moi' v LATE: <br /> ORALODate Service Completed (if already completed): SERVICE CODE: i E: <br /> S P <br /> Fee Amount: Amount Paid ' Payment Date S l <br /> Payment Typo Invoice# Check# O Received Sy: r <br /> lUl.(.Gofderi'Rod) <br /> EHD 48-02-025 <br /> REVISED 1111712003 <br />