Laserfiche WebLink
SAN JOAQUI.-4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �' t � CHECK If BILLING ADDRESS <br /> FACILITY NAME ' <br /> SITE ADDRESS `1�ynktST• X30 S• CQ1'[10"y o. 'SS'�c►�C�t�✓l. <br /> -13C 6tStreet Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING )DRESS (If Different fr m Site Address) <br /> OStreet Number Street Name <br /> CITY STATE Z <br /> V k C .a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> V C��l CG CHECK If BILLING ADDRESS <br /> BUSINESS NAME vv PHONE# EXT. <br /> ck <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE P <br /> zn <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: _ ROM)- U}0{2 2 DATE: n y- 25— 1Q. <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 locatede above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessor t n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it IS pr�py6pk <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: ^ /T <br /> COMMENTS: O� o �AnOgQ�1 <br /> Chi�n lVJ y ,.V QON'v COU <br /> FP 44 <br /> 'gRTM�NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Ll rI S 1 <br /> ASSIGNED TO: 1 vjV j1 1 EMPLOYEE#: DATE: L l <br /> Date Service Completed (if already completed): SERVICE CODE: P/ 1 <br /> Fee Amount: I S Amount Paic!17 D /77 Payment Date <br /> y <br /> Payment Type /h < Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />