Laserfiche WebLink
SAN JOAQlcOUNTY ENVIRONMENTAL HEALT `EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />1 1 / �m� �+ <br />BUSINESS NAME( 14 <br />SERVICE REQUEST # <br />I` <br />FAX#' <br />CITY STATE 75P <br />OWNER / OPERATOR_ <br />CHECK If BILLING ADDRESS ❑ <br />EMPLOYEE #: U Y <br />DATE: ci ZZ fi% <br />FACILITY NAME <br />� <br />�- <br />ear <br />d <br />r (� cLr-, I'll c <br />Fee Amount: -7 S'. Cl) <br />Amount Paid 3� S _ <br />SITE ADDRESS,�lj %y�(��YYIUiI�' <br />v`StreetNumber <br />Payment Type v,Invoice <br /># <br />S+� f��oda <br />Received By: L6 <br />7 5d; <br />Direction <br />Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE LP <br />PHONE #1T <br />APN # <br />LAND USE APPLICATION # <br />PHONE R ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO 1� `ri l �� CHECIC If BILUNG ADDRESS <br />1 1 / �m� �+ <br />BUSINESS NAME( 14 <br />P # E'iT <br />HOME Or MAILING ADDRESSr� <br />)Z6 1AJ`1Qk1aM <br />✓ <br />FAX#' <br />CITY STATE 75P <br />BELLING 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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this ap0lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDERAL la <br />APPLICANT'S SIGNATURE:aA� 0�� <br />DATE: (' 1 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILGING 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 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: <br />ECEI VE p <br />2 2 ?011 <br />SAN.JoAQU/tv <br />H�77g1R0NME OVN1Y <br />� OEPgR�EC <br />ACCEPTED BY: Q (� L v , }� <br />EMPLOYEE #: <br />z l <br />DATE: '1 1�22 !/ <br />ASSIGNED TO: Al <br />EMPLOYEE #: U Y <br />DATE: ci ZZ fi% <br />Date Service Completed (if already completed): <br />SERVICE CODE: l <br />P 1 E: <br />Fee Amount: -7 S'. Cl) <br />Amount Paid 3� S _ <br />Payment Date it <br />Payment Type v,Invoice <br /># <br />Check # <br />Received By: L6 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�i I` <br />