Laserfiche WebLink
SAN JOAQUI) UNTY ENVIRONMENTAL HEALTPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />cb <br />BUSINESS NAME —PHONE# <br />► I- c-0 <br />(.9cv9 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS El <br />AOVIN <br />MENT <br />FAX# <br />FACILITY NAME <br />41p, <br />SITE ADDRESS <br />420` ) <br />\ V l <br />CITY �Ib C <br />STATE (IC <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Vo Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SERVICE CODE: C <br />P 1 E: <br />�✓ <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />QCCP C'42 34 <br />Received By: / �,- <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�_3 io <br />CHECK if BILLING ADDRESS <br />cb <br />BUSINESS NAME —PHONE# <br />► I- c-0 <br />(.9cv9 <br />ExT. <br />1- 33 <br />HOME or MAILING ADDRESS <br />AOVIN <br />MENT <br />FAX# <br />(- 6I '- 6131-12 <br />41p, <br />ACCEPTED BY: <br />420` ) <br />EMPLOYEE #: <br />CITY �Ib C <br />STATE (IC <br />ZIP O <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, Stand -ads, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: A DATE: H - n_- Q L <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C <br />If APPLICANT is <br />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. ENT <br />TYPE OF SERVICE REQUESTED: J �� <br />RECE� <br />COMMENTS: <br />COUNTY <br />AOVIN <br />MENT <br />N E�1N17N DEPR <br />ACCEPTED BY: <br />EMPLOYEE #: <br />C <br />DATE: I OT <br />ASSIGNED TO: ' � <br />�, <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: C <br />P 1 E: <br />�✓ <br />Fee Amount: / <br />Amount PaidPa <br />ment Date ` <br />Payment Type - <br />Invoice # <br />Check #� <br />Received By: / �,- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED -11/17/2003 <br />