Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UEST# <br /> It<e- WOW <br /> OWNER/OPERATOR <br /> tCCE T / CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SACGN <br /> SITE ADDRESS ;16,9,9 S <eJ rl�� ,/ 0A o TR.4 <br /> y 9 s 3 04Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 5; l 5 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 620f) o7f-.7 N/,4 <br /> [PHIONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> tJC'^ CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME � PHONE# / EXT. <br /> ^ <br /> HOME or MAILING ADDRESS FAX# <br /> O ( ) <br /> CITY -ry Izz-OC44 <br /> STATE c k ZIP 4�3 <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 prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards ATE and RAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT Id <br /> If APPLICANT is not the BILLING PARTY,proof authorization to sign is required Tine <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 /> t0 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: Sof/1 FAQ a i4c O Er' 12RECEIVED <br /> COMMENTS: <br /> AIL 0 2 2019 <br /> SAN JOAQUIN COUN <br /> ENViPONMEPITAL <br /> HEALTH D=Fr,TiLSENT <br /> ACCEPTED BY: I EMPLOYEE#: DATE: ''f -Z_-Il <br /> ASSIGNED TO: f EMPLOYEE#: 7 DATE: 7 <br /> Date Service Completed (if already Completed): SERVICE CODE: �Z P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Typenvoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />