Laserfiche WebLink
6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SkA <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS Er <br /> FACILITY NAME <br /> SITE ADDRESS (y F , fin/(,/lj.. Mar�I✓► �-c S7 c c <br /> k Street Number 4tiv <br /> �tr� Namet k Yly Citv Zip 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 /> ((,!;D) 3-yL) 171 & G oo.--) <br /> PHONE#2 ExT. BOS DISTRICTATION CODE <br /> ( ► <br /> 001 <br /> TOC 0 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR (G CHECK If BILLING ADDRESS <br /> BUSINESS NAME C�`j PHONE# EXT. <br /> HOME or MAILING ADDRESS , •�Mt. �` FAx# <br /> CITY J r,) t fic�� STATE i 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: - DATE:_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER �rlOTHER 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 ava e t s e i�i <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L�Ih I jaZTnC/ µ <br /> COMMENTS: D E C o 1 2017 <br /> EWIRONiVlE-NI-AL HEALTH <br /> DEPARTN'lENNIT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 12-- I - L7 <br /> ASSIGNED TO: V-1 0&CIA,1 EMPLOYEE#: DATE: 1-1� _ 1 <br /> Date Service Completed if already Completed): SERVICE CODE: (I P/E: <br /> Fee Amount: !.E Amount L/C j Pa'ODymen_t1 Date /`7 <br /> Payment Type Invoice# Check# Is503 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />