Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Q <br /> K— I 7) <br /> SITE ADDRESS Z C ra <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING <br /> /ADDRESS (If Different from Site Address) <br /> Z L(� f(✓ ��.�-�- �� Street Number C't Street Name <br /> CITY STATE ZIP <br /> 7124( C7 j <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. IF SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR . / <br /> �L✓L'" (/' czlLt-a CHECK if BILLING ADDRESS <br /> BUSINESS NAME / / i PHONE# EXT. <br /> D/ plc-z/4� l 2ol3 3Yj-2')i L, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY f" ✓ G� STATE ZIP 0753 / <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 /> 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, S TE and FEDERAL w <br /> APPLICANT'S SIGNATURE: SIJ/") DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is requir Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: (J pA <br /> COMMENTS: <br /> JUN 0 5 ' 015 <br /> N' 40 ,v►� <br /> SAN jNO� <br /> AtDU1N CO <br /> UNTY <br /> Io <br /> i 1AVI <br /> 9 0� NEALH T <br /> ACCEPTED BY: EMPLOYEE#: DATE: / <br /> t0 <br /> ASSIGNED TO: Y T EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: I <br /> Fee Amount: Amount Paid 6 v O Payment Date <br /> Payment Type L e`I` Invoice# Check# /-j 3 ;k' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />