Laserfiche WebLink
9 t T • � i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> - SERVICE REQUEST <br /> Type of Business or Property FACILITY ID..# SERVICE REQUEST# <br /> hA <br /> '� 2 <br /> ,OWNER/OPERATOR <br /> Palo pada - <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS {�1j 1 hnM vLPM♦ - � ^ 24 <br /> Street Number Direction , Street Name Cit `-� Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. TAPN# LAND USE APPLICATION# <br /> ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> /A <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> _25 6� WULM 0144b ( ) 4 <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 or <br /> 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: 9S, _ 611 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Lam,. �2U <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title . <br /> --A RlteiTlON 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: <br /> PAYMFNT <br /> — -- <br /> COMMENTS: RECEIVED <br /> JUL 2 5 2012 <br /> SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY. EMPLOYEE#: DATE: `7 Z/ Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: (D <br /> Date Service Completed (if already completed): SERVICE CODE: ! G P I E: �I <br /> _Fee Amount: C Amount Paid <br /> � m <br /> j �✓ Payent Date Z� l <br /> Payment Type _ Invoice# Check# 0 Received B /1 <br /> EHD 4-8702-025 M <br />