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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT011) <br /> 1 CHECK if BILLING ADDRESS <br /> FACILITY NNIE k `1 <br /> SITE ADDRESS, \ �'�t� 10(,ro? <br /> ction19; yC\01`eeNName� (/,koA 5vC�� Zi Code/ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY � � $TATE ZIP9� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z011) <br /> PHONE#2EXT• BOS DISTRICT LOCA (O CODE <br /> 3 �7)t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ <br /> V CHECK If BILLING ADDRESS <br /> BUSINESS NAME —� !� PHONE# EXT. <br /> clas V yU� <br /> HOME or MAILING ADDRESSjQ FAX# <br /> Y� ( ) <br /> CITY Lia Liuv\ <br /> STATE CH ZIP �'- T 1 <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 /> I also certify that I have prepared this app' ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE d DERAL laws. r� <br /> APPLICANT'S SIGNATURE: //��DATE: C\ 1� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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 information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same t�Uo me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: -pot <br /> COMMENTS: OUNTy <br /> `SAN JO <br /> ``\\ ENVIRONMQUINETAL <br /> _) HEALTHDEpA4TMENT <br /> ACCEPTED BY: \ EMPLOYEE#: DATE: ��_ y� _7 <br /> ASSIGNED TO: i-7 V\�l EMPLOYEE#: DATE: . <br /> Date Service Complet (if already completed): SERVICE CODE: L PIE: <br /> L <br /> Fee Amount: C, C �C-, Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />