Laserfiche WebLink
SAN JOAQUIN-7UNTY ENVIRONMENTAL HEALTH "EPARTMENT <br />SERVICE REQUEST <br />Type of siness or P perty <br />1 <br />F <br />FACILITY ID # <br />SERVICE REQUEST # <br />)CL cIe,) 4.27,;5 <br />OWNER / PERATCI�� `�/ <br />1'�/�/��,�r ` v <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ow <br />2 <br />SITE ADDRESSJv <br />reef Number <br />rection <br />, Stmt Nai <br />STATE ZIP <br />SERVICE CODE: <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Payment Type <br />STATE ZIP <br />PHONE #t EXT. <br />ri <br />APN # <br />Received By� <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />L11 <br />C <br />CHECK If BILLING ADDRESS <br />L <br />BUSINESS NAME <br />'6 I <br />EXT. <br />PHONE r�� <br />HOME or MAILING DDRESS <br />2 <br />FAX # <br />CITY <br />%Kjj <br />STATE ZIP <br />FMA <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 TATE_gnd FEDERAL laws. (n ' /7- r� - <br />APPLICANT'S SIGNATURE: DATE: � <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLiNGPARTY, 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 />srj <br />L11 <br />C <br />COMMENTS:�1�1� <br />SAN JOAQUIN GO SV <br />AL <br />�NVIRO�pA� Mg[si' <br />ACCEPTED BY:! <br />EMPLOYEE #: <br />DATE: Z - <br />ASSIGNED TO: r <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: 23 <br />Fee Amount: �] <br />r <br />Amount Paid <br />— <br />Payment Date I <br />Payment Type <br />Invoice # <br />Check # <br />Received By� <br />SR FORM (Golden R d) <br />EHD 48-02-025 e$ <br />REVISED 11/17/2003 <br />