Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRO N AL HEALTH DEPARTNIFNT <br /> � � <br /> SERVICEEI Q& l' <br /> -_;•; - FACILITY ID SERVICE REQUEST# <br /> Type of Business or Property r- �O <br /> OWNER I OPERATOR 1� CHECK If Bf LUNG ADDRESS❑ <br /> FACIuTYNAME �'`� � 0-bb „e-Lm kol-C <br /> SITE ADDRESS Jig» o5'�r�i i- e Ikv�. v�- c 9533d� <br /> et Number iroetbn <br /> HOME or MAiLM ADDRESS (if Different from Site Address) l <br /> Street Number Strett Elm1 <br /> CITY STATE ZIP <br /> PHONE IF1 EXT. APN# G LAND Use APPLICATION 0 <br /> PHONE#2 exT 11 BOS DISTRICTC) LMATIONCODE <br /> � G <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR �06 �� / CHECK N BILLING ADDRESS <br /> PH E# EXT. <br /> BusmESS NAME <br /> HOME Or MAIuNG ADDRESS •FAX# <br /> CITYSTATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor project specific ENVIRONMENTAL HEALTH DEPARTMENT 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 1OAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE and FEDE L laws. <br /> APPLICANT'S SIGNATURE;. DATE: I i <br /> PROPERTYlBUSINESS OWNER❑ AERATOROVIANAGatO OTHERAUTHORIZEDAGENT1 <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE WFORMATICM: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize tate rei::ase of any and all results, geotechnical data andlor environmentaVsite assessment 1 <br /> information to the SAN JOAQUIN COUNTY ENN7RONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is <br /> provided to me or my representative. 1 <br /> TYP3: eREQuisTeD: `1h'e i �L �tl1(� r I <br /> eolt� '"- 1A S� �� -CIO <br /> �C ecery <br /> OCT l o o� <br /> &AH,IOAQUM i <br /> ulH cc HEALTM O ` LL <br /> 'twfT <br /> v nR�E?f T <br /> TIO <br /> EMPLOYEE#: DATE: <br /> ACCEPTED BY: <br /> ASSIGNED TQ: EMPLOYEE# DATE: <br /> : <br /> ) <br /> tA <br /> Date Service Completed (if already o pieced): SERVICE CODE: i P I E: <br /> 1 <br /> Fee Amount: 3 D"v Anwunt Pa,*0 /d �� Payment Date //lb <br /> Payment Type 15�� Invoice# <br /> Ch # �9 Recei By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 1 111 7120 0 3 <br /> £'d £9699686OZ wnelaledelgeiled egg:ZOt,l601o0 <br />