Laserfiche WebLink
SAN JOAQUOOUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property f'001,1/� FACILITY ID# SERVICE REQUEST# <br /> S Gas <br /> �rc�o-u 6� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction tMBlfie / C e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> -? —r <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> 3 ' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU TOR HECK if BILLING AD KESS❑ <br /> BUSINESS N E PHONE# EXT <br /> HOME or MAILING ADDRESS FAX# <br /> r ) <br /> CITY STATE ZIPre i <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 th t the wo o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F DE L la <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: <br /> COMMENTS: R <br /> AUL � 2008 <br /> COUNN <br /> SAN JOADv�NENTW- <br /> �TH pEPp,RTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: I -Ila <br /> Date Service Completed (if already co leted): SERVICE CODE: PIE: V <br /> Fee Amount: Amount Paid b Payment Date Il 6 % <br /> Payment Type >✓ Invoice# Check# o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />