Laserfiche WebLink
SAN JOAQ`_.4 COUNTY ENVIRONMENTAL HEAL'. )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE-REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME / J J_ <br /> l�L/ � <br /> SITE ADDRESS r 0 <br /> �2J C �/� <br /> Street Number Direction Stet Name Cit Zio Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20 1-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME -- PHONE# i EXT. <br /> 14 4 <br /> HOME or MAILING ADDRESS FAX# <br /> 2L) ( ) <br /> CITY 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 <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 Coder,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE-,, DATE; 2 -- 2 ,-7 — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IftPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 NF%y }p time it is <br /> provided to me or my representative. Nr <br /> TYPE OF SERVICE REQUESTED: `D <br /> COMMENTS: , 2020 S OAQU N CDUN <br /> ry <br /> HST M DIIISAIrAL <br /> CPA T NT <br /> ACCEPTED BY: ,1, EMPLOYEE#: DATE: 2-121120 <br /> ASSIGNED TO: C, '( 1 v`f� EMPLOYEE#: DATE: ,L <br /> Date Service Completed (if already comp) W ed): SERVICE CODE: P/E: <br /> Fee Amount: �2 Amount Pai �J�.w Payment Date27 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />