Laserfiche WebLink
SAN.TOA 'N COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> k 00 i0. ,Q- <br /> O ER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> ciuTr NAME <br /> 0A OU, <br /> SITE ADDRESS Zf 5 j 5- a a M wv� r� qZ <br /> Street Number Direction Street Name Cit Zi Code <br /> ME Or MAILING ADDRESS (If Different from Site Address) ��G�Gj <br /> Street Number ` Street Name <br /> CITY STATE zip G <br /> WGLlhl <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> l ) � I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> USINESS NAME PHaO�NE# EXT. <br /> HOME or MAILING ADDRESS FAA# <br /> SCIDI nl ) <br /> CITY STATE R 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepare his a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan s, TATE and E L laws. <br /> APPLICANT'S SIGN RE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT s t the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO EASE 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: � RECEIVED <br /> COMMENTS: NOV 2 7 i <br /> SAN JOAGIUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: )` EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: a EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: �( <br /> Fee Amount: Amount Paid �'� — Payment Date \ -;: 1 <br /> Payment Type Invoice# Check# a4� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />