Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T pe of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> e S �f��6 l �a SJ SRc�7g�1�1"� <br /> OWNER/OPERATOR <br /> AG CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �.,..�)r p,(� )wry�7•��y//� �J1LgV{^\ /��QJ', ('� <br /> © Street Number Direction • �l Street Name <br /> HOME Or MAILING ADDRESS (f Different from Site Address) <br /> Street Number Street Name <br /> CITYT TE ZIP <br /> PHONE#1 E.T. APN6LA ND USE APPLICATION <br /> 8 o-7q cO� <br /> —111 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) d.� O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q� <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PH NE# EXT' <br /> yo <br /> HOME Or MAILING ADDRES FAX# <br /> CITYSTA 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 w rk t 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: <br /> PROPERTY/BUSINESS OWNW OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICA I Ot 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. w <br /> TYPE OF SERVICE REQUESTED: O PA <br /> Y MEN I <br /> COMMENTS: <br /> Ck-)Q►'�j-Q 6�2 owner— JUL 3 0 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> LTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: O . 1 <br /> ASSIGNED TO: I �� EMPLOYEE DATE: - 50' <br /> It <br /> Date Service Completed (if already completed): SERVICE CODE: v) & PIE: C) <br /> Fee Amount: _ Amount Paid Jra Payment Date 7/30 / <br /> Payment Type e.y .�. Invoice# Check# '" - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/OB <br />