Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9 <br /> OWNER/OPERATOR., w �� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> eetNumber tion 1, `� re Name I Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) O Z 0 �n r <br /> St14 umber V "Street Nam'epi <br /> CITY � � $TATE - ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (loci) 741-Gq <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> C &' 'Z- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Nex2/ �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME. // PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY <br /> L r v� STATE /n ZIP QSZ� <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 n and that the work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATURES_ <br /> PROPERTY/BUSINESS OWNER L 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, 1, 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 pC2vided to me or <br /> my representative. Y� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> MA r <br /> SAN JO <br /> ENAUIN <br /> VIRON COUN7Y <br /> HERLTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: t <br /> ASSIGNED TO: 76h C' LJ—z- <br /> -7— EMPLOYEE#: DATE:eD_ t5- 1 -ServiceDate Service Completed (if already completed): SERVICE CODE: /l P/E: 1 nv <br /> Fee Amount: `-bo 0 Amount Paid ¢, / 2 G} Payment Date C / <br /> Payment Type �< Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />