Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRQNMENTAL HEALTH DEPARTMEtiiT , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ?t) - <br /> -T <br /> OWNER/ OPERATOR \ CHECK If BILLING ADDRESS❑ <br /> itii S C oL"D f A1C <br /> FACILITY NAME <br /> SITE ADDRESS �^ n <br /> .�01 OV 7 1(�l CST t N [tel me r <br /> Street Number Direction Street Name City Zip 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /// <br /> A` ^ 4 / ����✓ L/ f A p Q� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO E# EXT. <br /> A ) 3 6,-? <br /> HOME or MAILING ADDRESSn I FAX# <br /> �t�g2 <br /> CITY > STATE4fA ZIP 45L5WL' <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,STAIE and EDERAL I WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O TO / AGER OTHER AUTHORIZED AGENTt� l <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: <br /> COMMENTS: - ECEIVE <br /> $ 30� . <br /> AUG 2 5 2005 <br /> ` SAN JOAOUIN COUNTY <br /> Fr VIRONMENTAL <br /> HE _,H DEPARTMENT, <br /> ACCEPTED BY: EMPLOYEE#: I DATE: 42S <br /> ASSIGNED TO: EMPLOYEE#: } DATE: <br /> Date Service ompleted (if already completed): SERVICE CODE: -ZZ Z P I E <br /> Fee Amount: Amount Paid Payment ate y-�oS <br /> Payment Type ✓ Invoice# Check# /( 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />