Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r)C_cP �� C <br /> OWNER/ OPERATOR <br /> � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> RW- <br /> SITE C� <br /> y-SASD-DRESS 11 O-� ��„D v e— S' O C `L'� IA l — l <br /> l t Street Number Directi`o�nl Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYS TE ZIP <br /> � � <br /> -a -S- <br /> PHONE#'I EXT' APN# LAND USE APPLICATION# <br /> (c�� C4 152-- '3 1 � 9 1 33- v`f�o - z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COD <br /> ( ) C C <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: 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,Standards, TA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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: D N p N — A_)F C,& <br /> COMMENTS: t4 C <br /> SAN 3O,JI 'OU <br /> ;v <br /> CN1P'U <br /> ENTH OEPNIRTMEP1T <br /> ACCEPTED BY: i L/,E f ka—A EMPLOYEE#: C)`3 Zr DATE: �l O <br /> ASSIGNED TO: �� � EMPLOYEE#: C)j DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j()& P 1 E: (o,p2 <br /> Fee Amount: oo s,L.J Amount Paid 15 , Payment Date l\ <br /> Payment Type L Invoice# Check# D` 3 Received By: <br /> EHD 48-02-025 _S,R FRM(Golden'Rod) <br /> REVISED 11/17/2003 <br />