Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ` <br /> SITE ADDRESS <br /> Street Number Direction Street Name C!ty Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) )Li 333 U� 0., Q c� <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> 5 � c �s <br /> PHONE#1 EXT• AP�# �y r�V�' `/� Ll LAND USE APPLICATION# <br /> PHONE#2 EXT. 3 �l1 iJ1, BOS DISTRICT LOA ON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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,I,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: �Ot� h YK. 'fin Flo <br /> COMMENTS:Z'vy��lQ a^ cLo rte. -�r 0^.P- ��i./�Q e�C�F�� S� -t-y0.0. <br /> ACCEPTED BY: EMPLOYEE#: OO 2I DATE: <br /> �O 3 123' 17 <br /> ASSIGNED TO: J o EMPLOYEE#: V p DATE: 3 I I <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:kA `l0 <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 />