Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> LCHECK if BILLING ADDRESS <br /> FACILITY NAME I P�IFn V 0 <br /> (SIITTE ADDRESS (/ I Y 1 A <br /> _/ '1 V umber Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> _ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT�T APN# LAND USE APPLICATION# <br /> ('2A ��� ' ���� <br /> PHONE#2 EXT. — BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERN710E REQUESTOR <br /> REQUESTORa <br /> S" ' ��,� ��� CHECK IfBILLINGADDRESSQ <br /> BUSINESS NAME 14 f V ' PHON,�# �� r y��EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY CU pro <br /> STATE /1 ZIP <br /> BILLING ACkNOiriiLEDGEMENT: 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, S ATE d FE RAL laws. <br /> APPLiCAN T S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER P OPER 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 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. <br /> h <br /> T YDE OF SERVICE REQUESTED: C COOL) P <br /> COMMENTS: tiECEIVED <br /> SEP 302016 <br /> SANENVIAQUIN ROMENTA COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L Ll EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE <br /> Date Service Completed (if already compief d): SERVICE CODE: C&6e P/E: a]J <br /> Fee Amount: `fit I � Amount Paid ' 3 r9 U Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />