Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Nft.. SERVICE REQUEST ... <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ln' i <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> /moi? T cS f1Z5 <br /> FACILITY NAME <br /> 2 c'I-1 <br /> SITE ADDRESS /q 5 n/piZTN 211-01\/ R'04D >GG <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> fA - O - /l2 <br /> PHONE#2 ExT BOS DISTRICT --1[LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^^''••��/� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /V PHONE# EXT. <br /> (f q F_ Cp/J i-r/A)l <br /> HOME or MAILING ADDRESS FAX# <br /> /� ld-z�9 <br /> CITYn z-o C V- <br /> STATE �,^ ZIP �3 <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 ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and F RAL laws. <br /> APPLICANT'S SIGNATURE:- I//. "& zgw&.� DATE: <br /> PROPERTY/BUSINESS OWNER ElOPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPP[JCANT is not the BiLuNG 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 50 l L Su l TA 3 f L f T ST ✓J tai i�i r� r' I I�` <br /> COMMENTS: 1�/�` I� /�__ray. L� �� rwW►J J ,. -- <br /> r/ (/ `�• J DEC I 2008 <br /> uEALTH <br /> ENVIRONMEN► , <br /> PERMOT/S'tRVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: �G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5�v P/E: / <br /> Fee Amount: Z4Amount Paid Pa74 0 , 1yment Date Z <br /> Payment Type Invoice# Check# .,:,7 ! Recei ed By: <br /> EHD 48-02-025 SR FORM(GoI en Rod) <br /> REVISED 11/17/2003 <br />