Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> [bdii,pat oc\ F 37 7 3 .54006 2-99,0 <br /> OWNER/OPE OR <br /> 4 CHECK if BILLING ADDRESS E] <br /> FACILITY NAME n 660 Ua <br /> SITE ADDRESS '?�*, f Mq fd LiaA\ <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING <br /> iAD RESS (If Different from Site Address) <br /> L`4 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRE <br /> 1 <br /> BUSINESS NAME � PHONE# ' <br /> � l �u�t� <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) ZVA1 2- <br /> CITY STATE 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 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: W�3. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENT �y,�` <br /> IfAPPL1CANT'is not theB7LLINGPARTY 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: T <br /> COMMENTS: RECEiV E� <br /> JUL <br /> SAN o RONME� T <br /> �3-(1-1 DEP��EN <br /> ACCEPTED BY: Loa)e EMPLOYEE M -L 0,30 DATE: 7 �li II <br /> ASSIGNED TO: P 1-� EMPLOYEE#: !�/_�-?_ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J PIE:2 3 08' <br /> Fee Amount: ount Paid I Payment Date <br /> Payment Type I/ Invoice# Check# Received y: <br /> EHD 48-02-025Itid) <br /> REVISED 11/17/2003 <br />