Laserfiche WebLink
SAN JOAQU*LINTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />ron <br />BUSINESS NAMEPHONE# <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />T rLjL <br />PIZ <br />- 1 <br />SITE ADDR SS <br />Street Number <br />Ise'l- <br />Direction <br />t� <br />�(��` <br />`I' t � ree Name <br />CITY `1 <br />' ' <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Fee Amount: 2 C� <br />Street Name <br />CITY <br />Payment Type <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />( 1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUESTORii a <br />CHECK if BILLING ADDRESS <br />I V% l <br />COMMENTS: <br />BUSINESS NAMEPHONE# <br />L U <br />JUL 10 <br />SAN JOACQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EXT. <br />T rLjL <br />PIZ <br />- 1 <br />HOME or MAILING ADDRESS <br />Z Ctr� <br />EMPLOYEE #: <br />FAX# <br />) Z.- 50'7 <br />CITY `1 <br />STATEc `� ZIP qicsw <br />r� <br />SERVICE CODE: lqff <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 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 />�U�,��� +� <br />APPLICANT'S SIGNATURE: �-I I -t'150 DATES:: (� <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not theBul,INGPAR proof of authorization to sign is required/ ,� V 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 />ECEq\/E <br />COMMENTS: <br />L U <br />JUL 10 <br />SAN JOACQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:11 <br />PIZ <br />DATE: <br />ASSIGNED TO: V <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: lqff <br />PIE: ID <br />Fee Amount: 2 C� <br />Amount Paid 0 <br />Payment Date p <br />Payment Type <br />Invoice # <br />Check # 5 3 <br />Received By: �A G <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />