Laserfiche WebLink
1 � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT t ( �+ j <br /> CHECK if BILLING ADDRESS <br /> �� <br /> � ✓�`�_ � �-} C; -�vw�4�s.%' `.t�a.� <br /> FACILITY NAME JJJJ <br /> SITE DDRESS 1 <br /> 6 'L, .. (kcj Ute,Lov-CAI- <br /> 12-4, Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# <br /> /( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME � , S � `\ � PHExr. <br /> �#, L/O/ ._ /'r <br /> HOME or MAILING ADDRESS (� FAX# T �J <br /> � <br /> CITY 1_0 (, STATE r ZIP tJ, <br /> BILLING ACKNOWLEDGEMENT: 1, 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 d that t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE an FEDER <br /> APPLICANT'S SIGNATURE: L/C - DATE; :2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ UTHORIZED 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 Ine or my representative. <br /> TYPE OF SERVICE REQUESTED: i <br /> COMMENTS: eAY <br /> " WIN <br /> 2020 <br /> SAN JOA <br /> QUIIy <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: S EMPLOYEE#: DATE: z-) <br /> Date Service Completed (if already completed): SERVICE CODE: C P 1 (� <br /> Fee Amount: �, Amount Paid !� l Payment Date Ly <br /> c� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />