Laserfiche WebLink
SAN JOAQUII` )UNTY ENVIRONMENTAL HEALTI 1PARTMENT , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATE r CHECK if BILLING ADDRESS <br /> __�— •cel <br /> FACILITY NAME <br /> SITE ADD ESS <br /> Street Number Difection l� SZreet Name CI <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> P ExT rOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST / CHECK If BILLING ADDRESS <br /> PHONE# Ext. <br /> BUSINESS NAME <br /> FAx# <br /> HOME o• I Q_7DRESS� <br /> 5 ` ,f TATE ZIP \ <br /> CITY _ <br /> BIL G ACKNO�VLEDGEATENT: 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 applicati and that e work to b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standardg,STA nd FED ws• G <br /> — (( DATE' <br /> APPLICANTS SIGNATURE: �f <br /> PROPERTY/BUSINESS OWN vOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> proof o authorization to sign is required Title <br /> If APPLICANT is not the BILLING PARTY,p f I <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> "� <br /> TYPE OF SERVICE REQUESTED: S v <br /> COMMENTS: f�/^ ,/�P -� f�-Yit(C/4V) RECEIVE <br /> ApR 2 8 2ao4 <br /> SAN JOAQuIN COut4v <br /> ENVIFON'ME TMEt� <br /> ACCEPTED BY: EMPLOYEE#: H DATE: <br /> d ^ EMPLOYEE#: O I DATE: <br /> ASSIGNED TO: it (J S <br /> Date Service Completed (if alreadyom <br /> cpleted): <br /> SERVICE CODE: P I E: Q/ <br /> Fee Amount: <br /> Amount Paid 2111 Payment Datet f D y <br /> Payment Type <br /> Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 4B-02-025 <br /> REVISED 11/17/2003 <br />