Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNEr /OPERATOR <br /> / , n' ,f `J— /// ` fAR1 / CHECK If BILLING A0DRE5 <br /> FACT NAME / V T// (iV ��L /��t <br /> L� US <br /> Si E ADDRESS n e � �� �„ /_ _ L�•f'� �0 <br /> tree Number Direction S[ree Name CI `ZIi Code <br /> HOMES or MAILING <br /> ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP 1 <br /> PHONE#tEXT. APN# LAND USE APPLICATION# <br /> ( tel S77-O// -D 0 - 3P-- /bo 3 IP !G 43 So <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) QvLA L <br /> CONTRACTOR/ SERVICE REQUESTOR Pk <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME {jam/ PHON # EXT' <br /> -v ( 1 <br /> HOME or MAILING DDRESS FAX It <br /> CITY , O STATE CA ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or buLiness 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 /> also certify that I have prepared this appli tion that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA an E laws. <br /> APPLICANT'S SIGNATURE: DATE: �6 Z� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR f MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 1 L , / LfT ij <br /> COMMENTS: <br /> 40 <br /> ACCEPTED BY: EMPLOYEE#: DATE: l/-'qFN NJy <br /> ASSIGNED TO: , WS EMPLOYEE#: DATE: I ifFNp <br /> Date Service Completed (if already com feted): SERVICE CODE: v PIE: <br /> Fee Amount: Amount Pai �j4j5 L)Z) Payment Date 1, � /" <br /> Payment Type I, Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />