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 /> CHECK If BILLING ADDRESS <br /> ♦ Y <br /> FACILI NAME . <br /> C L`.S L�/ C d Q I e.l 1 C- <br /> SITE ADDRESS LJ ��j/ <br /> Street Number DIF�Ction Street'Nam� <br /> HOME ONAILING ADDRESS (If Different from Site Address) [/(^/ G /es <br /> -CO1. I Street Number `J Street Name <br /> CITY Mode STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 2 ! as <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 MOM <br /> jjj <br /> CCU— <br /> � y� O M-&">O0 I I ICA CHECK If BILLING ADDRESS <br /> BUSINESS NAME l� n� V PHONE# L EXT. <br /> C i /40 30 <br /> HOME or MAILING ADDRESSFAX# <br /> � -1)r ( > <br /> CITY Sln STATE L_ ZIP 9�s�S 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 /> 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 an EDERAL laws. / <br /> APPLICANT'S SIGNATURE: i DATE: (ice �Z'zz Z <br /> PROPERTY/BUSINESS OWNEPI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS Ilot 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 /> to 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 /> TYPE OF SERVICE REQUESTED: 1'!�' <br /> COMMENTS: <br /> O U3`n�-/meq SAA]joSN <br /> -�c��; <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> - -7 <br /> ASSIGNED TO. EMPLOYEE#: DATE: Ll <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: l �3 <br /> Fee Amount: 1 Amount Pa i /` g 00 Payment Date <br /> 2�1-� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />