Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Ob <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> ��� )•� �• CHECK If BILLING ADDRES <br /> FACILITY NAME � � <br /> SITE ADDRESS I.�_^ erJc�/,7� �y � 1757,q <br /> ^/TC—6,19-1 <br /> Street Number erection Street Name / city Zip Code <br /> HQME or MAILING ADDRESS (If Different from Site Address) <br /> yJ'I//✓ SG Street Number Street Name <br /> CITY STATE ZIP <br /> S T <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> a ) 61;- �G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( ) <br /> HOME or MAILING ADDR S FAX# <br /> ( ) <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: 215 ,4 - � C.Z� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BmLiNG PARYT 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: S/ . r <br /> COMMENTS: tRA G�1v C'� <br /> SPR 13 206 <br /> GGUNS`I <br /> SPN 3�R NW RSM�Nj <br /> ACCEPTED BY: EMPLOYEE#: 310% Ifo <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6 PIE:2-3// <br /> Fee Amount: c� Amount Paid 9-? D Q Payment Date <br /> Payment Type Invoice# Check# Received By: z� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />