Laserfiche WebLink
SAN JOAQUIIOUNTY ENVAONMENTAL HEALTIEPARTMENT . <br /> `' -41 <br /> SERVICE REQUEST 4 " <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( bc3Cf <br /> OWNER/OPERATOR <br /> ED <br /> CNECK:If BILLING ADDRESS <br /> FACILITY NAME L <br /> SITE ADDRESS <br /> I2treet Number ction Street Name city Zip,Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> �1SC /- � '54 Street Number Street Name <br /> CITY <br /> STATE Zip <br /> C— <br /> PHONE#1 ExT• APN}Y LAND USE APPLICATION# <br /> 'PleNE411 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAMEPHONE# ExT• } <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE Zip <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 farm <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,STATE an FEDERAL laws. <br /> ip <br /> APPLICANT'S SIGNATURE: tr DATE: 2 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/N AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,f APPLICANT is not the BILLING PART).proof of authorization to sign is required Title s <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 /> i ! <br /> provided to me or my representative. i <br /> TYPE OF SERVICE REQUESTED: S -AF-Ac-,E �t c,r6,5-u FP4c-F <br /> COMMENTS: <br /> Q Fri (C6;1'C c ✓L�. d l���L_c G�4 >v'7cv' � D F <br /> �{ECEIV�D <br /> 31(���s <br /> /M; <br /> c� j 1S1 COUNN <br /> ACCEPTED BY: EMPLOYEE M j Z I DATE:, <br /> f 1 <br /> ASSIGNED TO: 6o�� _� EMPLOYEE M C)I—1 I DATE: -n—O 0 C <br /> Date Service Completed (if already completed): SERVICE CODE: 3 r s P 1 E: �.03 <br /> Fee Amount: (�(A vv Amount Paid Payment Date A O S <br /> Payment Type _A-& Invoice# Check# Received By: <br /> EHD <br /> REVISED 11117I2003 '5-WFORM:Golderil�iA <br /> ••- � -_�� -�-� <br />