Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sUZ 6-7a I t <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> c <br /> "�C-fi Lti GLC C� <br /> SITE ADDRESS ^^\\ vlevx <br /> ; <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �oa2 C� -�a✓1�� �-� iQ'- <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 1 C� 61o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 6-,a-37 a_ <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 1 ) <br /> HOME or MAILING ADDRESS FAX# <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 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 1, 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (�(,(,f� `-} (Y� ✓v u <br /> COMMENTS: <br /> 0- -nv.L�O # t v = �e-�- c t re4 n -t- <br /> A- -A C r►�le U �'l 'S-("7-t Z 7` (o <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: lit 1 EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): L1_ L�_ •' SERVICE CODE: 1-t <br /> 7,L P I E: 6 j <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />