Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ; FACILITY ID# SERVICE REQUEST# <br /> wNvie ✓Y <br /> OWNER i OPERATOR <br /> e,/'n � ��e✓✓� CHECK If BILLING ADDRESS <br /> FAciury NAME � C C4 ✓'Le✓r <br /> SITE ADDRESS / I <br /> ---------7n <br /> W <br /> Street Number Direction Street Name city Zip Code <br /> HOME Corr MAILING ADDRESS (if�Different from Site Address) <br /> I* I W, ��"L'�CI..�. TZc( Street Number Street Name <br /> CITY bcG�c vrt po STATE Zip <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> ( 7a f 003-17v-Jo <br /> PHONE#2 Ear, BOS DISTRICT L( SON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 identifie on this form. <br /> I also certify that I have prepared this application that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not)#e BIL LING 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 JOAQURJ 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; 7i7axfmT <br /> COMMENTS: RECEIVED <br /> 7 = �J NOV 1 6 2007 <br /> //�>�> ✓"I P�Pi�PI! C%/�/i�fc/+7 �r' UNTY <br /> �-3��`�NVjgON� IMENOTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE MDATE: <br /> ASSIGNED TO: EMPLOYEE#: C DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: ?j PIE: <br /> Fee Amount: TN Amount Paid l 0-0 Payment Date Ll — IL_p—j <br /> Payment Type L_ r Invoice# (�� j7j Check# /-t'�;Z_ Received By: -Zz <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />