Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A 15c s s�'-ooSiS50 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> u� C-PJI <br /> FACILITY NAME L�1G <br /> SITE ADDRESS I L_I i C V1�l V e►� �„J G��' S�'�L.1�J C�SZp c] <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Q Cq Ae– <br /> L J Street Number Street Name <br /> CITY /D G/ STATE ZIP .3/J <br /> PHONE#1 EXT APN# LAND USE APPLICATION# j <br /> i1k28 - o -777 <br /> [PH,ONE#T EXT. BOS DISTRICT LOCATION CODE <br /> 5� e 8 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� ovv e� f���� CHECK if BILLING ADDRESS r v■ <br /> i//1`�' CCC/// / <br /> BUSINESS NAME � ;CV �I IS � � PHONE# EXT. <br /> HOME or MAILING ADDRESSI` )��/ �cN. C C �� FAx# <br /> CITY L /_ STATE ZIP l)Llj / <br /> 3 1 <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 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 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, 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 a same time it is <br /> provided to me or my representative. q� <br /> TYPE OF SERVICE REQUESTED: �Oj C 0 r,,-s't knJAY1^ VE <br /> COMMENTS: •''� 16 <br /> N�avi� 0� vVvv�✓���� SE J7AQUIIy ?019 <br /> N��j�EPgR r�N1Y <br /> ENT <br /> ACCEPTEDBY: 7 � � EMPLOYEE#: DATE: <br /> ASSIGNED TO: `J , Acmict o EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ,tel 0 I P I E: 1002 <br /> Fee Amount: - GJZ O Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />