Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES1# <br /> OWNER/OPERATOR <br /> r&,-e <br /> ve ^ Y'C� "•Z CHECK If BILLING ADDRESS® <br /> FACILITY AME <br /> SITE ADDRESS <br /> 2 ( / S� <br /> J Street Number Direction C ( ! St4 Name C�CI <br /> HOME or MAILING ADD SS If ifferent from Site Address) <br /> Z ~ Street Number GL S/t eet Name �C <br /> CI STATE ZIP <br /> oc f-- ?S Z/S� <br /> PHONE#1T' APN# LAND USE APPLICATION# <br /> 7 2(Z' f c`7� 2$ 1 Og /93-- o -s2 ,m <br /> PHONE#2 EXT• SOS DISTRICT LOCATION CODE <br /> 3 a-577 <br /> CONTRACTOR/ SERVICE REQUE3TE3R <br /> REQUE R <br /> L_ .� `_Z y CHECK If BILLING ADDRESS <br /> BUsI ESS NAME !/ PHONE# EXT. <br /> HOME or MAILING ADDRES / FAX# <br /> c <br /> CITY ZL„C /n 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 form. <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 laws. Q ` <br /> PPLICANT'S SIGNATURE: DATE: O 7 / /tJ <br /> PROPERTY/BUSINESS OWNEROPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT is no the BILLING PARTY proof of authorization t0 sign Is required 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 /> to 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. Q <br /> TYPE OF SERVICE REQUESTED: SLL/I n l/naba ] �j vLe <br /> COMMENTS: q ; L� <br /> (nFC11e6 <br /> 1rAq 0 <br /> M_ � tSCQYlO SAN 208 <br /> EN�AOUi1v Ot/N <br /> ACCEPTED BY: Q,�A, EMPLOYEE#: DATE: Nr <br /> �"A )'ME r <br /> ASSIGNED TO: S EMPLOYEE#: DATE: �� 9— <br /> 114 <br /> Date Service Completed (if already completed): SERVICE CODE: --1- PIE: <br /> Fee Amount: a Amount Pa ��b b� Payment Doa�te) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />