Laserfiche WebLink
SAN JOAQi •`COUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> � REQUEST# <br /> AL L 54CU(-12757 <br /> OWNER/OPERATOR / C <br /> 2. LA LL CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS MAR/P05A CD- STOelMolt GIST/S <br /> OQ Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ` E:*' APN# LAND USE APPLICATION# <br /> PHONE#2 Ear- BOS DISTRICT LOCATION CODE <br /> ( , <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> ,JP_ <br /> O <br /> HOME or MAILING ADDRESS FAx# <br /> P. 0 , ( ) n' 00-'? <br /> CINR LD STATE i_ ZIP r3 Q/ <br /> BILLING ACKNONVLEDGEMENT: 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 appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: to —/ 7-05 <br /> PROPERTY/BUSINESS OWN ER 11 OPERATOR/4ANAGER El )dT <br /> HER AUTHORIZED AGENT,c� <br /> E <br /> If APPLICANT is not the BILGING 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: A//TRA E LOA /N 0/1 S 1>T L/ TGe D <br /> COMMENTS: PA <br /> �fkiL�.l .�z,[ RCCEIVED <br /> 2005 <br /> SAN JOA00N COU <br /> ACCEPTED BY: / EMPLOYEE#: -1 -1 <br /> ASSIGNED TO: , - EMPLOYEE#: C( -I Li DATE V <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount AL Llr 5 00 Amount Paid Payment Date 5 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />