Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> r� � CHECK If BILLING ADDRESS <br /> r C <br /> FACILITY NA <br /> SITE ADDR� 7 d�� <br /> -� Street Number DrrecTon `�Na `�'`� /?-CI /ZI 4;e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 \\� <br /> Street Number C)��) (-dstre Eiar�re <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR -7 <br /> REQUESTOR <br /> _ CHECK If BILLING ADDRESS <br /> BUSINESS NAME /�) PHONE# — EXT. <br /> 7 <br /> HOME Or ILING ADDRESS <br /> FAX# J <br /> CITY � �. STATES, 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 FE t—RAL laws. <br /> --1 <br /> APPLICANT'S SIGNATURE: DATE: -- <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑� 19 b7 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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 f0 me or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: � l" RECEIVED <br /> COMMENTS: MAY 0 1 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �\f,`'V`�"�/ EMPLOYEE#: DATE: i <br /> ASSIGNED TO: W\ EMPLOYEE#: DATE: <br /> Date Service Completed(If already completed): SERVICE CODE: V PIE; V <br /> Fee Amount: �'r Amount Paid S�_ Payment Date // <br /> Payment Type ;a Invoice# Check# 6 Received By: <br /> EHD 48-02-025 ?j4�- <br /> �t SR FORM(Golden Rod) <br /> 07/17/08 <br /> �o �� A 3 LO J <br />