Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C� STOC is Tti� itj <br /> pp< <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from SiteAddress) <br /> Z <br /> r E �h I�� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# -J L' LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT� LOCAIIQN CODE <br /> 623i J 1 C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 9 <br /> /v lA 1 r CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> PA P /� l`�K c�TG � (2,j ) �2 - �2 <br /> HOME or MAILING ADDRESS FAX# <br /> LAT Lkbc, <br /> CITY STATE ZIP <br /> uC k �Oti i L( <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. 1 <br /> APPLICANT'S SIGNATURE: /L/�0-' r-D^ 1Sl DATE: /2 — d i7 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/M NAGER ❑ 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, 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 assessment infoknation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided 'TI <br /> my representative. ,'�T <br /> TYPE OF SERVICE REQUESTED: 1 V��/)/� I rC n C�' Q j� VA��) <br /> COMMENTS: / (/t I[� .Q� P_/ J�Z�C q tl <br /> 1 �► t J SAIV JOA ! o�� <br /> 4C- lC K(�1 LISL- HEaCT Ro'P/ °uNrY <br /> AR k,ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: to <br /> ASSIGNED TO: HL EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: P/E: f �/ <br /> Fee Amount: 1 C� 4C? Amount Pai , /,5-:2,0(-,- Payment Date ���'��7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />