Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rA�� <br /> OWNER/ORATO <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �77— <br /> SITE ADDRESS rI I e <br /> �` Street Number Direction 9""" <br /> HOME Or MAILING ADDRESS (If Differgnt from Site Address) /f <br /> ` Street Number 'Street Name <br /> CITY ^� STATE /I� ZIP <br /> PHONE#1 L/ ET• APN# LAND USE APPLICATION#f <br /> r' 6 .J -,12—,,7-x 1 C50 <br /> PHONE#2 EXT. BOS DISTRICTATION CODE <br /> ( ) C) Irc <br /> C-) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORi <br /> n CHECK if BILLING ADDRESS <br /> no\ <br /> i <br /> BUSINESS NAME PHONE# iy EXT. <br /> HOME or MAILI?JGL�QD ESS FAX# <br /> `- .' I� ( ) <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 /> I also certify that I have prepared this application and that th work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE RAL law . <br /> 11 1 <br /> APPLICANT'S SIGNATURE: DATE: " <br /> PROPERTY I BUSINESS OWNERJGI� OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT f <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title A <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at t ��Dbpg <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment i �•z"�,�r <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided to rT tiv,, <br /> my representative. / �`® <br /> TYPE OF SERVICE REQUESTED: � (�� SqN J 2018 <br /> COMMENTS: ' ). �tI Fygv�T/ pA,/N C U <br /> NrY <br /> '14 <br /> FNr <br /> ACCEPTED BY: EMPLOYEE#: =DATE: _n <br /> c OC <br /> ASSIGNED TO: L Z EMPLOYEE M DATE: 7- <br /> Date <br /> _Date Service Completed (if already Completed): SERVICE CODE: O J PIE: V,` <br /> Fee Amount: G Amount Pai 1��, v (� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />