Laserfiche WebLink
-; - SAN JOAQUINWNTY ENVIRONMENTAL HEALTH IWRTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY IDS/# <br />✓ , <br />ERV CE E <br />�r/� =Si 12� r, l <br />BUSINESS NAME � f � �• <br />1� 000 1 O ( -7 <br />PHONE # <br />/ \ <br />'5)� 3V <br />OWNER I OPERA <br />DATE: <br />CHECK If BILLING ADDRESS <br />HOME or MAILING ADDRESS o <br />P <br />FACILITY NAME <br />h11941 ✓h e -r Lane- 76 <br />SITE ADDRESS <br />`A' <br />ZIP <br />l 1 a m&- <br />T� � <br />Invoice # <br />I <br />2 Cl) L- Street Number <br />Direction <br />v- <br />Street Name <br />City <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT (� <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR tit <br />���_ �9 <br />CHECK If BILLING ADDRESS <br />✓ , <br />ACCEPTED BY. <br />BUSINESS NAME � f � �• <br />DATE: �. <br />PHONE # <br />EXT. <br />t <br />DATE: <br />Date Service Completed (if ¢ady Completed): <br />HOME or MAILING ADDRESS o <br />P <br />FAX# <br />CITY / _._. <br />STATE 14A <br />ZIP <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 and that the work to be performed will be done in accordance with all SAN JOAQuw <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. �17i <br />APPLICANT'S SIGNATURE: �ftiy�� / �Yi I DATE: <br />PROPERTI" / BuSINESS OWNER ❑ OPERATOR /(\TANAGER ❑ OTHER :AUTHORIZED ACEN'I'-51 <br />If AP! LIC9NT is not the BILLING PARTY, proof'of authorization to sign is required Tirl e <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 environmentalisite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anda ie same time it is <br />provided to me or my representative. PAYI\A <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />MAR 1 <br />SAN JOAQUIN COUNT`( <br />VIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY. <br />EMPLOYEE #: <br />DATE: �. <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if ¢ady Completed): <br />SERVICE CODE G <br />P <br />Fee Amount: <br />Amount Paid <br />31 S c <br />Payment Date 3 t ( O I <br />Payment Type 1.5 <br />Invoice # <br />I <br />Check # I Received By: <br />EHD 45-02-025 �{ <br />SI? FF�RI,1 iGoiden Body <br />REVISED 11/17/2003 <br />