Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ UE # <br /> ES/!7 � r V <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS D <br /> '4'9-90M— C. <br /> FACILITY NAME <br /> SITE ADDRESS x6 783 A/ 015-6-T 2— <br /> Street <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 000 ) a10-3�o3 005-i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME N_ L PHONE# 2 _L EXT. <br /> o2oq)4oHOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY a RLOG([ 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 preparedthis ap ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, AT and Fe AL laws. <br /> APPLICANT'S SIGNATURE: DATE: /9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 1horization <br /> OTHER AUTHORIZED AGENT <br /> If APPLICANT IS not the BILLING PARTY,proof of a to sign is required Tire <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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: A a e�5u <br /> COMMENTS: KLIGEIVED <br /> FEB 0 6 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEA <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid —:SO4- Payment Date Z (o lU� <br /> co I <br /> Payment Type Invoice# Check# S T Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />