Laserfiche WebLink
SAN JOAQUI"' COUNTY ENVIRONMF,NTAI,HEAL"'"' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t, bcl �ur�i S � rid L <br /> OWNER/OPERATOR {n- <br /> Gr- \ �r CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEI ADD�+ORR�E,)S(]G],) L <br /> 1 `� `-' `��' Street Number Dimon Gaw �~ Slree amOe `-� C- <br /> it ZI Code <br /> HOME or MAILING ADDRESS (if <br /> (if Different from Site Address) <br /> 5 `-v ' 6 Street Number Street Name <br /> CITY S TEZIP <br /> r 3 <br /> Y2Z <br /> PHONE#1 EXT. APN# IFfSO `a-OI �-� LAND US VILICATION# <br /> 516 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> (eve 4g i 3Z 33 <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REOUESTOR �eL�e <br /> 1 Y� CHECK If BILLING ADDRE55E] <br /> BUSINESS NAME PHONE# EXT. <br /> z <br /> HOME or MAILING ADDRESS FAX# <br /> Ili } S Ma , ( ) <br /> CITY _ i L' <br /> STATE ZIP -Sev) <br /> BILLING ACKINOWLFDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-ICALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to ape Imed t I be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Standards, STAT'C and FL•DCRAI ws. <br /> APPLICANT'S SIGNATUR �� Dnre: �' 3 �� <br /> E <br /> PROPERTY/BnslNlss OWN' DI•EItAT011/MAN C R, OTNHIt ADTIIOmZED AGENT 11 <br /> 1JAPPLIC'ANT is 1101 the BILLING PdaTY / oof of authorization to sign is required Title <br /> AUTHORI7,A'r1ON TO RFLF,ASF, 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 ENVIRONMEN'T'AL HEALTH DEPART MEN'r as Soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: � 1�O�l/l9 DATE. <br /> Date Service Completed (if already completed): SERVICECODE: SZ 5 I E: O 2- <br /> Fee <br /> Fee Amount: Amount Paid Payment Date 3 <br /> Payment Type Invoice# Check# 13 Received By: <br /> ��ac�o3- Idl r. used VI <br /> EHD 48-01-025 SERVICEUEST FORM <br /> RF-VISFD C-5-02 919-710 3- � h r. u-�GL � <br />