Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business orProperty FACILITY ID# SERVICERR�t UEYT# / <br /> ' OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> IL <br /> FACILITY NAME <br /> SITF Annorcc / /) f �/� / S �n6 <br /> Jtreet Name CI Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> �O S I Street Number Street Name 2- <br /> CITY STATE ZIP <br /> S-�© tori C A CtS, ZO <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOP. O > CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> eelz f - <br /> HOME Or MAILING ADDRESS � !,/ (AX# ) <br /> CITY C•Li`// 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I p T(y� DATE: L�:/x�/zo/J- <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required TI rle <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It to me or <br /> my representative. N <br /> TYPE OF SERVICE REQUESTED: I_��CJ(.t V� (L eC E® <br /> COMMENTS: 2015 <br /> SAN <br /> Lf C. JOA ca�/�, <br /> NE�rN 1OE p� �NTY <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5.Z v <br /> ASSIGNED TO: I. , EMPLOYEE#: DATE: �-ZI . / <br /> Date Service Completed (if already completed): SERVICE CODE: CA-0 J P/E: ' 3 <br /> Fee Amount: I Amount Paid % �� Payment Date <br /> Payment Typeti: Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />