Laserfiche WebLink
SAN JOAQUJIIWOUNTY ENVIRONMENTAL HEAL EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />P ' A ..Exr. <br />(HONE ) <br />FAX # <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />OWNER /OPERATOR <br />CHECK ❑ <br />It bol <br />if BILLING ADDRESS <br />ffqbv) <br />FACILITY NAME I ^-•� <br />t <br />Fee Amount: <br />SITE ADDRESS /,, b5 <br />`� <br />�,. <br />V. `c"C00% ®. <br />w a, <br />. <br />152 tV <br />Street Number <br />Direction <br />Street Name <br />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />pyo <br />Gi <br />YYrr <br />') <br />Street NumberF <br />Street Name <br />-CtTY--------- a------- --- ------ <br />----- - _ - --- --STATE--------------ZIP_- - — ___ - <br />PHONE #1 E.T. <br />t1C[5 <br />APN # <br />LAND USE APPLICATION # <br />'PHONE #2 ExT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK <br />If BILLING ADDRESS <br />(`j <br />BUSINESS NAME( <br />//,, <br />iQdnC� <br />P ' A ..Exr. <br />(HONE ) <br />FAX # <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />EMPLOYEE #: <br />CITY JSTATE 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. i <br />APPLICANT'S SIGNATURE: - DATE: aim <br />PROPERTY /BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT m <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required -� Title <br />AUMORLZATION 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 O F SERVICE REQUESTED.' <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />5 <br />EHD 4eO2-025 S.R`}871CotdeOKftod) <br />REVISIED 11/17/2003 <br />