Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR" I , CHECK If BILLING ADDRESS <br /> FACILITY NAME C� <br /> SITE ADDRESS <br /> S <br /> 55 <br /> �1.• Street Number Ot{reotian I ee ham I ZI Catle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> str¢e[Numb¢r Street Name <br /> CITY STATE ZIP <br /> PHONE#1 T APIN LANG USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) O� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME t t PHONE# T' <br /> m <br /> HOME OrMAILINGADDRES FAX#q -07�3 <br /> 1P U . U Qor) / C <br /> CIN / o 1>1 STATE , ZIP c� 7j1� <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan S, STATE n D ws. <br /> APPLICANT'S SIGNATURE: DATE: �l <br /> PROPERTY I BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not a 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. PAYMENT <br /> L /- <br /> TYPE OF SERVICE REQUESTED: (J r f (/r / �.t�/i RECEIVED <br /> COMMENTS: MAY 0'3 2016 <br /> t2pw«5 SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S� PIE: dL& <br /> Fee Amount: - Amount Paid a 6 0 0 Payment Date S'- 3 16 <br /> Payment Type ; S Invoice# Check# Received By: <br /> EHD 48-02-025 t SR FORM(Golden Rod) <br /> 07/17/08 Ju/� <br /> I' IVT�� `I <br />