Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C� co <br /> WNE /OPERATOR <br /> !' CHECK If BILLING ADDRESS <br /> L <br /> l <br /> FACILITY NAME <br /> S TE ADDRESS <br /> �] (//,I / <br /> O / Street Number Direction SttZIde `/I <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ,1 EXT. APN# LAND USE APPLICATION# <br /> l° --� 7 0 1 <br /> PHONE 42 EXT. BOS DISTRICT LOCATION COD <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n/�SJ �� <br /> Y� CHECK If BILLING ADORES <br /> BUSINESS NAME j/ PHONE# EXT. <br /> i IAS <br /> HOME Or MAILING ADDRESSto <br /> FAX# <br /> CITY STATE ZIP F� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized4a'acknowledge that all Slte and/Or project SpeCIfIC ENVIRONMENTAL HEALTH DEPARTMENT hOUrly Charges aSSOClatedI �df(� <br /> activity will be billed to me or my business as identified on this form. Ty OF y4r, /yTy <br /> also certify that I have prepared this application and that t to be performed will be done in accordance with all SAN Jo QIJN6&f <br /> COUNTY Ordinance Codes, Stand s, STATE and FEDERAL la s. <br /> APPLICANT'S SIGNATURE: DATE:O 1 //17 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT ❑ <br /> I{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 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: `� <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ♦J` I, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Pal Payment Date Z <br /> Payment Type Invoice# Check# Receive By. - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />