Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> / S161VI/lIow 4 <br /> OWNER9 ERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY'NAME <br /> SITE ADDRESS n t�0 1 U (A <br /> Street Number F vection Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> (Z ) �3�1 - �o ���- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU PIR / D <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY i STA E ZIP <br /> Ci 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 ap cation and that the wor/obe e will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S and FEDER law.$. <br /> APPLICANT'S SIGNATURE <br /> (: DATE: - <br /> PROPERTY/BUSINESS OWNER 124J OPERATOR/MANAGER ❑ OT R AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tilie <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: L/� RE�,�Vflvr <br /> COMMENTS: it,ti VIFO <br /> JUL 0 3 2019 <br /> 3qN�OAQUIN CO <br /> HEAL Vj it p paENTq�TM <br /> ACCEPTED BY: L(20 rM EMPLOYEE#: ? DATE: 7 <br /> ASSIGNED TO: `J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r7 P/E: <br /> Fee Amount: Amount Paid I� Payment Date -713111 <br /> Payment Type �' Invoice# Check# Received By: <br /> Off-nF'g-- g32K9o7S <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />