Laserfiche WebLink
SAN JOAQUII0OUNTY ENVIRONMENTAL HEALTH _ —PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -2 <br /> IT <br /> ER/QPERAT\V � C CHECK If BILLING ADDRESS <br /> FACILI NAME _ <br /> CA <br /> SITE ADDRESS <br /> \_ H;4 <br /> 7 6 CA �St et Number Direction treet Name city <br /> Zi Code <br /> HOME or MAILING ADDRESS (If Rifferent from Site Address) S 20S <br /> C C' Street Number J Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 6- o G/3 j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME \ P ONE ExT. <br /> L=�Z"�: -E\r c' e� c ' G <br /> HOME or MAILING ADDR SS FAX# <br /> C' <br /> CITY C STATE ZIP QjS 2a+ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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. l <br /> APPLICANT'S SIGNATURE: c Spxq, DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTfWR 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: md <br /> COMMENTS: <br /> MADA p 40,4 0 5 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: _ M JACNI;D EMPLOYEE#: DATE: <br /> ASSIGNED TO: „ l� /�n EMPLOYEE#: DATE: 1 L <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: �S 2, Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />