Laserfiche WebLink
� 1 <br /> SAN JOAQUIN COUNT)' ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o2_3 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> c 4d L3c <br /> Street Number Direction Street Name <br /> city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site dddressl G7���" ,/`"x <br /> S� -N� ' " �� Sheet Number / <br /> Street Name <br /> CITY <br /> STATE ZIP � <br /> PHONE#1 ExT. AP # <br /> LAND USE APPLICATION# <br /> �a ► d t'- V I Z 4 <br /> PHONE#Z ExT BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � <br /> C___ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# _ O EXT. <br /> L 216 lG <br /> HOME or MAILING ADDRESS FAX# <br /> -- /Y7 71LIP GT- 4,4` ► <br /> CITY 5/—C) <br /> %C)0<�_.O---- <br /> ( /) 'c7- <br /> ,5l/0 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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: a <br /> I ROPER'rT'/BUSINESS OWNER OPER.aT R/YIANAGER ❑ OTHER AUTHORIZED AGENT�(►2,U'/ �� <br /> If APPLICANT is not the B! NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS INF011141ATION: When applicable, [,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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C) <br /> COMMENTS: _ <br /> LZ 61 dLA-oj�AYMENT <br /> AUG - 2 2011 <br /> ACCEPTED BY: Q LEMPLOYEE#- >3 N ENT <br /> ASSIGNED TO: UI <br /> EMPLOYEE#: / DATE: Z Er <br /> Date Service Completed (If already Completed): SERIVICE CODE: p/E: 3 <br /> Fee Amount: 2,? C� Z t �t <br /> S. Amount Paid Payment Date <br /> Payment Type Invoice# Check# g Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />