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SAN JOAQW. .OUNTY ENVIRONMENTAL HEALTH D_. ,RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#, <br /> OWNER!OPERATOR env; <br /> CHECK If BILLING ADDRESS <br /> F .uTv NAMEINIP�t, /�Qta) �� , 4LrA41 <br /> SITE ADDRESS ct2 ' <br /> "reef Number Eecli.n t ars;: itv <br /> f:7ME O; MAILING.A00 Lf Dd:arenntt from Site Address) <br /> / Street Number _eetName <br /> CIl (7T, STATE ZIP <br /> PHONE#1 1 EXT. APN# LAND USE APFI -ATION# <br /> PHONE#2 "c-PICT __]I " rlr­[; _ 9 <br /> CONTRAC"I OR/ SERVICE REQUESTOR <br /> REQUESTO R,-�l � �� (� I �p — <br /> •r-1} CHECK If BILLING ADDRESS <br /> BUSINESS NAMEoV PHONE# CE EXT. <br /> CIS . I � ' NJw C�N� �' 1 C � � A o'1 15 70 <br /> HOME or MAILINr;ADDVESS FAX# <br /> CITY A STATE <br /> C4 <br /> ZIP q 5 ' '7 6 <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 ENVIRO AL LTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identifie this fo <br /> also certify that I have prepared this application dat t e w o be performed will be done in accordance with all SAN JQAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and DE AL law . L I / <br /> APPLICANT'S SIGNATURE: _ DATE: ty a $ l D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M HER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not file BILLING PARTY,proof of ut /zation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When appli-.able, I, the owner or operator of the property located at '.1e ahove <br /> site address, hereby autho,ize the release of any and all results,geotechnical data and/or environmental/site assessment i .formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provld"d to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Z=(>� {_ <br /> COMMENTS: 1 i <br /> SOV 3 <br /> SA0 VSD <br /> C��� qN 2016 <br /> 16 <br /> NF�h D0 A <br /> ACCEPTED BY: EMPLOYEE#: DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SEPV�cr CODE: C)(C' P/E: Z <br /> Fee Amount: tk) Amount Paid' ribcv Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />