Laserfiche WebLink
SAN.TOA U. QTY ENV 4 <br /> Q ENVIRONMENTAL HEAL? RTMEN'T <br /> SERVICE REQUEST i- � <br /> Type yp I{siness or Property � FACILITY I©#- - - SE=RVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS Eh <br /> —N <br /> FACILITY NAME <br />' SITE ADDRESS <br /> s-8 <br /> i Street Number Direction Street Name city Zip Code r <br /> i <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> i a /t-p'-I Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE PPP6RATION# <br /> I PHONE#2 EXT. BOS DISTRICT I OCATIDN ODE - <br /> CONTRACTOR 1 SERVICE REQUESTO 0.47). <br /> REQUESTOR I <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `G PHONE# EXT. <br /> ( 1 <br /> HOME Or MAILING ADDRESS N FAX# <br /> yi1,,eo-N /tW- 2d t <br /> CITY STATE ZIP <br /> Cr /- <br /> !F <br /> I 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 n <br /> activity will be billed to me or r y 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 and FEDERAL la <br /> APPLICANT'S SIGNATUFEy: DATE: <br /> PROPERTY/BUSINESS OWNER[[71 PERATO /R'IANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANTis�not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> � C <br /> TYPE OF SERVICE REQUESTED: sf,( SC(/'��� � A <br /> COMMENTS- ' Z <br /> RECEIVED <br /> .IAN 9 2004 . <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTALENT <br /> AGCEPTED BY: M EMPLOYEE 0 D DATE: <br /> ASSIGNED TO: EMPLOYEE#: 5 DATE: <br /> k Date Service Completed (if already completed): SERVICE CODE: ?) PIE <br /> Ib <br /> Fee AmoVnt: Amount Paid 0' Payment bate l i <br /> 14 <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />