Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY In fi <br /> / - - SERVICE REQUEST# <br /> S744 1t 4h J7-/ (,�V <br /> OWNER/OPERATOR II y <br /> t&C L 1.J G 3� e11,A-C-u, CHECK If 131LLING ADDRESS® <br /> FACILITY NAME l <br /> SITE ADDRESS � JQ. �r <br /> Street Number Irectlon S�r�e Nt ame CI yC deb <br /> HOME Or MAILING ADDRESS (H Different from Site Address) <br /> Street Number Street e <br /> CITY STATE zip <br /> PHONE#1T APN# <br /> LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> t�`� ` / CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE M `� - <br /> HOME Or 11 <br /> LING ADR\ESS art/ / JJ� /-� FAX# - <br /> 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 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 E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> L C7 <br /> PROPERTY/BUSINESS OWNEfinot <br /> OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANthe 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 vided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MA Y <br /> yRO UIN COUNTY <br /> MAY 16 2017 N D p M NT <br /> ACCEPTED BY: E ':, EMPI.oY,pgRTAL HEALTH DATE: ti--/ <br /> RW71 <br /> ASSIGNED TO: 1 l C J EMP-LO f 1-NJ DATE: c <br /> Date Service Completed (if already completed): SERVICE CODE: l I q Ci PI E: <br /> Fee Amount: O Amount Pgi<ty L. 1-7,Q D <br /> [ � Payment Date ��1 <br /> Payment Type %L Invoice# Check# v j Received By: - <br /> EHD 48-02-025 <br /> 07/17/08 b SR FORM(Golden Rod) <br />