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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P�v o �LoC, <br /> OWNER/OPERATOR <br /> q>hCi`7C- CHECK If BILLING ADORES <br /> FACILITY NAME <br /> SITE ADDRESS SSa % <br /> Street Number Direction V Street Name CitG/GJ Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT --]F-LOCATION CODE <br /> ( ) b T- L\04 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> VIPOf�la X�un� iNi� 1A • ft, aos-/537 <br /> HOME or MAILING ADDRESS FAX# <br /> 'B� a S (9P14) <br /> CITY F-=,L6 66W-1 STATE C 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 /> 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 andnt <br /> APPLICANT'S SIGNATURE: DATE: rLy <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> ifAPPLICAN 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 /> to 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: l � �° �f <br /> COMMENTS: <br /> OCT � X013 <br /> HE EN AAOA9E COVNIy <br /> AL7N pEpA ?-p4z'W <br /> ACCEPTED BY: . � �� EMPLOYEE#: DATE: v Z 3 j 3 <br /> ASSIGNED TO: T/ % EMPLOYEE#: Z �, r f_ 6 DATE: <br /> Date Service Completed of already completed): SERVICE CODE: PIE: <br /> Z 3 <br /> Fee Amount: Amount Pai 37S U0 I <br /> Payment Date � 3 <br /> Payment Type Invoice# Check# g3tj2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />