Laserfiche WebLink
Jul 07 06 09: 42a Jeffrey C. Henley 714-739- 1499 p. 2 <br /> SAN JOAQU9COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if E$LUNG ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> t7"-2-% Street Number Direction Street Name C' Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT. APN# LAND USE APPLICATION# <br /> 1 <br /> PHONE#2 Err. SOS DISTRICT LOCATION CODE <br /> i 1 <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK ifBILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> trj ( <br /> CITY STATE tE, 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 /> 1 also certify that 1 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 an laws. <br /> APPLICANT'S SIGNATURE: "�~ DATE: -7, <br /> PROPERTY/BusmEss OWNER❑ OPERATOR/ GER ❑ OmER AUTuoR1zED AGENT Er— <br /> If APPL/e4NT is not the BILLING PARTY proof of authorization to sign is required Titre <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 COUM ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. AV- <br /> TYPE OF SERVICE REQUESTED: _0 S <br /> COMMENTS: <br /> PQU1N GO <br /> SP�Nv1a�NMS�MENj <br /> STN Del? <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 �� <br /> ASSIGNED TO: �� ` EMPLOYEE#: ® 7 DATE: <br /> Date Service Completed (if already comp d): SERVICE CODE: __ 92 1 PIE: 2-�If <br /> Fee Amount: Amount Paid Payment Date 17 <br /> 1(066 <br /> Payment Type Invoice# Check# S Received By: <br /> EHD48-02-025 �A <br /> REVISED 11/17/2003 -� _j <br />