Laserfiche WebLink
1 <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property r-U dd/ FACILITY ID# SERVICE REQUEST K <br /> �Fa�� <br /> IMO <br /> OWNER/OPE T R �� U I�rlS USU CHECKHBILLINGADDRESS❑ <br /> �Q. c0 <br /> FACILITY NAME <br /> SITE ADDRESS / �' C-h Q-t e-r WO-1 S t'O w,4o AJ <br /> Street Number Di.wn Street Harr» C ZI Code <br /> HOME or MAILING ADDRESS (If Dlrrerent from Site Address) 935'� (f 3-n I- nJ <br /> Street Number S t a <br /> CITY C3CK�.� STATE ZIP <br /> C lT <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (go9 ) �o$- <br /> PHONE*T ExT• BOS DISTRICT LOCATION CODE <br /> ( C) ) 6 79 Ll <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK K BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"'' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLFDGF.MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENV1RONmENTAL HEALTH DEPARTmEPTT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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 an e laws. <br /> APPLICANT'S SIGNATURE: � DATE: y-Q^f-0)-e <br /> PROPERTY/BUSINESS OWNER II'J OPERATOR/MANAGER IT OTHER AUMORIZED AGENT❑ aWLy <br /> IfAPPUCANT is not the B/IJJNG PARTY.proof of authorization to sign is required Tirte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: i f- VE <br /> COMMENTS: <br /> SAN,, 0 ?�?0 <br /> NFgLTy 16tcyD COU <br /> IV <br /> ACCEPTED BY: EMPLOYEE M �� DATE: L1 U Z� <br /> ASSIGNED TO: c w�`c'� �J - (— EMPLOYEE M ` DATE: 1 j �� <br /> Date Service Completed (tt already completed): SERVICE ODE: `l //,' P i ; <br /> Fee Amount: -� Amount Paid �s� D v Payment Date l0 <br /> Payment Type !S%x Invoice# Check# 107` 7 330 Received By: / <br /> j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />