Laserfiche WebLink
SAN JOAQUTA COUNTY ENVIRONMENTAL HEALTH APPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> '' rn f� CHECK if BILLING ADDRESS <br /> FACILITY NAME f I c )f` 0 <br /> SITE ADDRESS �;� �/ R '9 po F T <br /> Street Number I Dlrecuon I cl f�1 `] Zip CodeJ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 670I.`►1 AyE Street Number Street Name <br /> CITY'c STATE (� ZIP 61-7 Z4 d <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z01 ) Sb - -Z 6 23 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> c92ss — <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 5'Q1, ��pl�1 y�Q 7 t CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> GIHuM 1 C <br /> HOME or MAILING ADDRESS FAX# + <br /> kad 19 VE c > <br /> CITY I<Ttl STATE yf, 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 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> c 5— tit <br /> PROPERTY/BUSINESS OWNER a 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 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it IS pp _to me or <br /> my representative. M <br /> TYPE OF SERVICE REQUESTED: Con S o n �!/ <br /> COMMENTS: I VIAJ r1 <br /> ���SCI^] 2015 <br /> LI L NE,A NVIROMN COIN <br /> TN OEPgq��N <br /> ACCEPTED BY: �1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' P/E: I a <br /> Fee Amount: , Amount Pa 3� U Payment Date �//�//.� <br /> Payment Type /)(� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />