Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> St2rd�p3oc{f6Y <br /> OWNER/OMT <br /> / l �\7 CHECK if BILLING ADDRESS O <br /> FACILITY NAME ! \/ /�/„_ ^ { �\` \ / e _ <br /> SITE ADDRESS l�./( �y�7 l� I-{ L� �� �L(�_ <br /> Street N tuber Direction '1 Street Name Ci Zi Code <br /> HO orLING ADDRESS (I D' erent from Site Address) <br /> Street Number Street Name <br /> CITY ST TE Zip / <br /> (H NE11 exT. APN# LAND USE APPLICATION <br /> PHONE 9— iO Q Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR <br /> CHECKif BILLING ADDRES <br /> BUSINESS NAME ,. ` _I_ ^^ /) ^ O f �, PN N IO� ExT <br /> F{OME or eLIN FAY <br /> RY ZIP 4 <br /> Bh.LING A RNOWLEDGEMENT: 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 apph tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST an L laws. <br /> APPLICANT'S SIGNATURE: C DATE: <br /> PROPERTY/BUSINESS OwNE OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is no the BILLING PARTY proof of authorization to sign is required <br /> AUTHORIZATION TO REL ASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby a thorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQ N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my represe tative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ��� �1 <br /> A.N JGAu-J[H UUJNI r <br /> APPROVED BY: 1 o, <br /> EMPLOYEE#: 'Z'L�L 'limo : . ./ .� �: [•+. ww Q. <br /> ASSIGNED TO: S S> N EMPLOYEE#: -73 O DATE:d 17-09 Ort <br /> Date Service Completed (if already completed): SERVICE CODE: SC <br /> OG2 <br /> Fee Amount: iLs00 Amount Paid '-/',L/ — Off' Payment Date p <br /> Payment Type 7 Invoice# Check# - t <br /> F/f%ice Received By: <br /> EHD 25 <br /> REVISEDSED 6-5-02 SERVICE REQUEST FORM <br /> & <br />