Laserfiche WebLink
MEMNON <br /> M <br /> SAN JOAQUIN ' OUNTY CINVIRONMENTAL HEALTI `1EPARTMENI' <br /> '' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�X10 3 311;0OWNER/ OPERATOR I ' <br /> L U t_yl N � ns CHECK if BILLING ADDRESS <br /> FACILITY NAME bbb d ' <br /> SITE ADDRESS �(tj( %Ck tA I j,t rf7 �d I C <br /> l J�. 4r i i <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> S Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# _ I LAND USE APPLI AT N# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I CHECK if BILLING ADDRESS D <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY �j` 0_0 Al STATE C/\ ZIP ct S_2-/." C <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 HEALTfI 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 thisappli ti n an a the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'T'Y Orclinculce Codee,SlnncfrHcls,SI, I'E a id F I`a\ws. <br /> APPLICANT'S SIGNATURE: /\ DATE,: �I l <br /> PIt01'F.NTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIH,,itAUTHORIZED ACF:NT `� V <br /> /f <br /> APPLICANT is not the BILLING PART;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 (lie <br /> above site address, hereby authorize the release of any and all results, geoteclinical 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: <br /> COMMENTS' � � . ��? rl /ZZ o RECEIVED <br /> '�� '� p� 7 �dt 60 � t'wMAR 2 7 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC NTALT EALTHIDES <br /> N S10r; <br /> APPROVED BY: L EMPLOYEE#: 2Z DATE: _ Z <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: "3 Z <br /> Date Service Completed (if already completed): FSE RVICE CODE: 3i7 P/E: 'I C, <br /> Fee Amount: I 1 Amount Paid 1V;�'��, Payment Date D,7 a 3 <br /> Payment Type Invoice # Check# Received By: <br /> EHD 48-01-025 t .CP ^� SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />