Laserfiche WebLink
t \ n7 <br /> SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATCIR <br /> '� ��.,^ri CHECK if BILLING ADDRESS <br /> FACILITY NAME Ckl <br /> SADDDRESS t ��CA4 g l J� '� C l� 101S&A <br /> `4� Street Number I IDivrection Street Name C Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ph Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 J Err. APN# LAND USE APPLICATION# <br /> (2d� )g3Z gaC�Cv <br /> PHONE#Z EXT, BOS DISTRICT LOCATION CODE <br /> (2CA ) g 3 z S8 2ro G e-)4 0 0 3(A-7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOG C� l e" CHECK if BILLING ADDRESS❑ <br /> 1:.� C fit. � .2.0� �O/ <br /> BUSINES NAME PHONE# EXT. <br /> HoM or MAILi ADDRESS FAX# <br /> �S"� ) D <br /> CITY STATEcla 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 <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 Ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLicANT 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: //��� L p <br /> COMMENTS: N L S E.� iris ` r tJ LLL �C�7VC T <br /> I `D <br /> Sati JO ?9 Zd�p3 <br /> y E7AW04 Opti <br /> EaLn�cq�N/Y <br /> PA— <br /> ACCEPTED BY: EMPLOYEE Ll <br /> DATE: 7 O <br /> ASSIGNED TO: 4 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE <br /> Fee Amount: I Amount Paid * 3�p , Payment Date 91 2�� <br /> Payment Type tl� Invoice# C Check# l$ct 2_ Received By: �(�-- <br /> EHD 48-02-025 J v 6 O ` at q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />