Laserfiche WebLink
SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTH*PARTMENT <br /> + SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C 5-ro 2C— r S�� 1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME //-�Ys* 'c / <br /> h�-( ( � <br /> SITE ADDRESS %\i / 'p C/L Of/J i� i <br /> +� Street Number Direction Street Name Ci 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 /> ( ) '✓� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ---I,," <br /> ✓✓n f S �i�� CHECK if BILLING ADDRESS <br /> BUSINESS NAMEi V-'I f l /�' PHONE# EXT. <br /> ctz callHOME or <br /> 1AILING AD RESS FAX# <br /> I 97 1 &'9'1e-C 0n;i"f- o) 7`/f - 7q � <br /> CITY ,PI K-Vnt -s 'ttkt C-4--t- TATE ZIP 9-.c-� )_ <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,ST FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERAT /MANAGER ❑ OTHER AUTHORIZED AGENT. <br /> 14f t� <br /> If APPLICANT is not e 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: (AS'—i <br /> COMMENTS: i3(Litt Z Gv T Ly .t 5/Q Ca ''J �Temic�� e$'1�7 51se2 O ��r+tel i✓l v�' ' l+�A <br /> OCT2a? ° <br /> jo, 16 <br /> H�'h'TRONMF�U <br /> ACCEPTED BY: EMPLOYEE#: DATE: E <br /> ASSIGNED TO: �c N� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE; ( P 1 E: <br /> Fee Amount: D Amount Pale41-7-06 Payment Date <br /> Payment Type Invoice# Check# •�-� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />