Laserfiche WebLink
SAN JOAQUU "OUNTY ENVIRONMENTAL HEALT"DE"TMENT <br /> SERVVYRIK' QUEST ~ SERVICE REQUEST# <br /> aADDRFACILITY ID# ��oD 433Sg <br /> E <br /> ss or Property U <br /> SCHECK If BILLING❑ <br /> ERATOR «Z 4- , r vec zl codeti St eet Namestreet Number DirectionING ADDRESS (If Different from S/ite Address) street Name2r v `/ STATE ZAP^ #�/ LAND USE APPLICATION# <br /> �N <br /> PHONE#2 <br /> Ext BOS DISTRICT LDGATIDN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �/<�� / CHECK If BILLING ADDRESSLL71 <br /> PHONE ' <br /> BUSINESS NAME <br /> HOME or MAILIN ADD SS / FAR# z6 / <br /> (ZO ) 334- / <br /> r•DY / STATE : z"' Z �1 O <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 fbrm <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 JOAQLJIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. Q <br /> APPLICANT'S SIGNATURE: u DATE: p - Z —05 <br /> PROPERTY/BusiNEss OWNER OPh TOR/MANAGER ❑ OTHERAUTHORIZEDAGENTT9 <br /> JJfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <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 samepme. itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ' I <br /> COMMEMS: <br /> AU2 2005 <br /> AOUINENU <br /> SAN VI ME <br /> N <br /> tiENTH DEP ENT <br /> �GJ <br /> ACCEPTED BY: EMPLOYEE#: O 4� DATE: 2- <br /> ASSIGNED <br /> ASSIGNED TO: �In .. EMPLOYEE M _ -3� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r PIE: 3 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />