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SAN JOAQ.iN COUNTY ENVIRONMENTAL HEALI ti LJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 07NER I OPERATO, r\kA <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> t--)k CtrV 1��V�C. t C C=. C -re(zvo <br /> SIT�ADDRE %" <br /> b Street Number Direction � S ree Name CI 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 FXT• APN# `` ? l LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) I - L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I I � I C'� � P, 'C, 3 J <br /> HV 4�MgIL ADDRESS` i �,e c� (� Fax# <br /> I( v _ J `� 1 ( ) <br /> CITY <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: r, t LGl Lki DATE: (k � t <br /> PROPERTY/BUSINESS OWNExist <br /> PERATOR/MANAGER C J OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICAN 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 It IS provided to me Or <br /> my representative. pp�� <br /> TYPE OF SERVICE REQUESTED: �)� I ) ' t I N <br /> COMMENTS: D• <br /> AU <br /> SAN h 02 2017 <br /> Joj <br /> j�Ff �NVIRpNM COUIyJY. s <br /> �/ STH QFP <br /> ACCEPTED BY: EMPLOYEE#: DATE: �'( .• r <br /> ASSIGNED TO: V J EMPLOYEE#: DATE: % -) <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: /�� <br /> Fee Amount: C-1 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 />