Laserfiche WebLink
SAN JOAQU*­�'"OUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br /> SERVICE REQUEST <br /> + Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR n I <br /> 36- H <br /> t � C� 0, _ CHECK if BILLING ADDRESS LJ <br /> FacrLITYNAME � "� <br /> �\P�03 _ Com$ S ��-=-.5 Uz <br /> SREADDRESS <br /> Street Number Direction Street Name CiN Zip Code <br /> H E Or MAILING ADDRESS (If Different from <br /> Site Address) <br /> Street Number Street Name • <br /> CITY STATE Z[P <br /> PHONE#t ' APN# LAND USE APPLICATION# <br /> �0�) � 1 } 1 1�L� a 31 �-00.3 �� - �3_ Si, u <br /> C PHONE#2T BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT• <br /> rl <br /> HOME or MAILING ADDRESS FaX# <br /> CITY STATE ZIP <br /> I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aclmowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project o -' <br /> activity will be billed to me or my business as ident&ied 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 STA nd FEDE ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BfLaNG PARry proof of authorization to sign is required Time <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 /> TYPE OF SERVICE REQUESTED: L r o t-(1b ck)4�s'1-r-- PAYMENT <br /> COMM NTS r.t r <br /> � � � ( JUL <br /> ., <br /> SAN JOAQUIN GOUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: CU L[ V f EMPLOYEE#: �, ?� DATE: 7 [oS <br /> ASSIGNED TO: VA-,J \'/,-)E EMPLOYEE#: U�0 DATE: `7 <br /> Date Service Completed (if already completed): SERVICE CODE: 5-2-2- PIE: Lf Z O $ <br /> Fee Amount: r G O J Amount Paid � . D� Payment Date -� D <br /> Payment Type �/ Invoice# Check# SrS Received By <br /> k� EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> r <br />