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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus ness or Property FACILITY ID# SERVICE REQUEST# <br /> �� <br /> OWNER/OPE OR <br /> 1 �ar CHECK if BILLING ADDRESS El <br /> FACILITY NAME Tncoz `r <br /> Au s [��Dlreci�qc\ 1vw a ocvAoc\�"Zo <br /> StreetNumber Street Name Ci <br /> ZiD Code <br /> \tjiF or ILING AD RESS (if Diff @rcent from Site Address) �`� „ <br /> J { (( �� '\'_ , ` `rib <br /> V U I 3t eet Nu a Street Name <br /> CITY C n co STATE �I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2c9, q <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR G \— r e—\ c\ CHECK if BILLING ADDRESS E] <br /> -RucZINESSNM'�4 PHONE-#. EXT. <br /> 1 <br /> Ho r MAI< u qD` ( ) <br /> CITY\ f\ � FAX# <br /> � TE ZIP C� <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 FEDERAL laws. / <br /> APPLICANT'S SIGNATURE:(::5 Y( / —F'Y'� i�C f'� DATE: <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, 1, 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 assessment1nformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi.1 _me or <br /> my representative. "��rr <br /> TYPE OF SERVICE REQUESTED: F� <br /> COMMENTS: 3 <br /> �GTyO�p RFN q�^''Y <br /> TMFNr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date ->115611 <br /> Payment Type Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />