Laserfiche WebLink
SAN JOAQLjuJ COUNTY ENVIRONMENTAL HEALTH LJcPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU�,sT# <br /> OWNER/OPERATOR v� ; . C1AN�1�v <br /> rt CHECK If BILLING ADDRESS <br /> FACILITY NAME � 1V A ,�)iA <br /> SITE ADDRESS <br /> 3�Iss r= C R T C et Na To C�-TCN q I S <br /> Street Number Direction Street Name Ci ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (� G RC)0 e <br /> O U� e'e t' Street Numher Street Name <br /> CITY STATEzip <br /> S To c -ToN C.-A. 9 22 D <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME V PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <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 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: t �G�� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MA GER ❑ 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: j " . PAYMENT <br /> COMMENTS: RECEIVE <br /> FEB 10 2015 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I /1 EMPLOYEE#: DATE: •2� /O <br /> ASSIGNED TO: A /v i � EMPLOYEE#: DATE: <br /> Date Service Completed (if alrea4y completed): SERVICE CODE: C. PIE: Q <br /> Fee Amount: Z-pl -, Amount Paid �d Payment Date � tib �5 <br /> Payment Type i Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />