Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ON���,� <br /> OWNER/OPEf2ATOR <br /> CHECK If BILLING ADDRES <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site dress) <br /> umber Street Name <br /> CITY &TATE ZIP 7 7 <br /> C <br /> PH E#1 EXT. APN i LAND USE APPLICATION# <br /> ( - �-2C-z <br /> 7- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE XT. <br /> J # ��(,7-KY�l 7 <br /> HOME or MAILING ADDR SSFAX# C <br /> CITY /� _ STATE ZIP ' ) <br /> BILLING ACKNOWL DGEMENT: 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ( DATE: JC%l J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR-I-RIIANA OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time.jti's provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �� APR 262019 <br /> 6 ?019 <br /> HE,qqQU <br /> H,0O�� UIV7y <br /> eVT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alread completed): SERVICE CODE: �� A: <br /> Fee Amount: 0 Amount Paid _ Payment ate / ,4 1 <br /> 't <br /> Payment Type Invoice# Check# lki� Received By: ( - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />