Laserfiche WebLink
NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus i�5st7- <br /> Prop", FACILITY ID# SERVICE REQUEST# <br /> fCL j '� o <br /> OWNER/ OP RATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME /� /c n �,n 14 „�r�„ <br /> PM <br /> SITE ADDRESS / c�/vI f <br /> 6' <br /> Street Numbe� �c�rfoh' 'StYe�tNailf f� i Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY iM a ) STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ��4 , � <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ° t � � 1LCL��ti'G � PH�FtJ) ,r`., EXT. <br /> HOME or MAILING DRESS l� FAX# L`JC�Xl1 <br /> CITY vy C STATE ZIP <br /> BILLING ACKNOWLEDG ENT: 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 TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATES: <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: JU'V y Q <br /> S,qN JO l 8 2008 <br /> y ' NQ/R QUIN C <br /> �T/yDFpgR��N�Y <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: ;1 9-p DATE: Q <br /> ASSIGNED TO: EMPLOYEE#: �/ r/ DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: G" Amount Paid w Paymen -Date <br /> Payment Type Invoice# Check#, 0-9 1 Received By: �r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />