Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -13 ILOnL) 14S <br /> OWNER/OPERATO <br /> C. �1 CHECK If BILLING ADDRESS❑ <br /> S�Ia0 C,✓� <br /> FACILITY NAME <br /> SITE ADDRESS f -77 <br /> --713 Street Number Direction Street Name -t�0 t C6& CiTtK eX <br /> W 2i Cod -2 :11 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ?, 6 G S U Street Number Street Name <br /> CITY STATE zip <br /> C `'I J-v r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (X)01 ) q �I --13704 r3ei -os2 -�3 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( �' ) O( � -� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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,STA and FEDE L wS. <br /> APPLICANT'S SIGNATURE: —� DATE: v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 <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: (,L j C O A/,S C T74 %-'? r� A,' <br /> COMMENTS: RECEIVED <br /> ANk U 2 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTIVIPhrr <br /> ACCEPTED BY: U ( ( V E I b-,4- EMPLOYEE#: �( DATE: .�U <br /> ASSIGNED TO: A fV c EMPLOYEE#: C� t S DATE: -1� <br /> Date Service Completed (if already completed): SERVICE CODE: v r P 1 E: s t <br /> Fee Amount Amount Paid Payment Data 2—� <br /> Payment Type l Invoice# Check# Received By: �S <br /> EHD 48-02-025 SR FORM(Golden`Rod) <br /> REVISED 11/17/2003 <br />