Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I r-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2 ���5 <br /> OWNER/OPERATOR <br /> V e-Y!llJ CHECK if BILLING ADDRESS El <br /> FACILITY NAME— V <br /> cos lu ora rr�^ C� <br /> SITE ADDRESS C� t( G,< 11 c� 0 3 <br /> _�0 Street Number Direction 6 Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I C' <br /> - AddCCLYY <br /> Street Number Street Name <br /> CITY C-9 $TATE <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> CC?) 6g -55440/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i <br /> e-` , 9' O icy <br /> ® CHECK If BILLING ADDRESS <br /> BUSINESS NAME �f PHONE# (� EXT. <br /> HOME or MAILING ADDRES FAX# <br /> S �Y ( ) <br /> CITY / STATE <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 th form. <br /> also certify that I have prepared this application and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE nd FED L laws. <br /> APPLICANT'S SIGNATURE: G ;C' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ 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 located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess m entdcffmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prov* r <br /> my representative. `Ar <br /> TYPE OF SERVICE REQUESTED: 1l0 Q 3 Fcpgi I ( e 1t ''11i�•�' <br /> T <br /> COMMENTS: SgNJ 6 ZD <br /> COUN <br /> pgRTMFNr <br /> ACCEPTED BY: T d; A EMPLOYEE#: � DATE: Wd4//-7 <br /> . yti�i <br /> ASSIGNED TO: I 5 EMPLOYEE#: /CC] �� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: % Amount Pai` /s� b U Payment Date Z(j 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />