Laserfiche WebLink
! 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 7 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESW) �—z <br /> et Number Direction Street Name ' � <br /> ` Zi Code <br /> HOME or MAILING ADDRESS (If Different from S' Address) C <br /> Street Number Street Name <br /> CITY <br /> STATE ZIP <br /> PHO #1 ExT• APN# LAND USE APPLICATION# <br /> 2t�� <br /> PHONE#ZT• DISTRICT <br /> ,� BOS LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A/ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# ExT. <br /> HOME or MAILING ADDRESS �� FAX# l <br /> CITY <br /> L�VIc <br /> ( 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 <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 appliland that the work to b performed will be done in accordance with 1 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAD+ L laws.APPLICANT'S SIGNATURE: f <br /> DATE'PROPERTY/BUSINESS OWNER❑ OPERNAGER R AUTHORIZED AGENTIf APPLICANT is not the BILLIpr f of a orization 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 end at the same time it is <br /> provided to me or my representative. NqY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: —2i <br /> AY <br /> S4NJ `� 20o Jr <br /> H�CT�R NM CDUN <br /> N�FP4R MINT <br /> ACCEPTED BY: / EMPLOYEE#: <br /> DATE: <br /> ASSIGNED TO: a <br /> A/2-� EMPLOYEE#: DATE: <br /> Date Service Completed dy completed): SERVICE CODE: <br /> P/ <br /> Fee Amount: t1 Amount Paid Payment Date <br /> Payment T <br /> Y Type Invoice# Cheek It h u6�C�, Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />