Laserfiche WebLink
NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gas 3 <br /> OWNER/OPERATOR, <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME �C n i mar_ _ <br /> Cp U•.� I' �L 1 �. <br /> SITE ADDRESS N9 <br /> n/ 1 e 2 1_+ <br /> Street Number Direction Stree 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 /> (a0q ) -S3'4�90 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Wn PHONE ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> LO c k)cxh 00 <br /> CITY 1 _ STATEn yt ZIP C3 <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 /> 6 <br /> APPLICANT'S SIGNATURE: Q DATE: +e /� ,,� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT yl?A-L)i Cie Cn-A `0-4-r- <br /> If APPLICANT 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 available and at the same time it is <br /> provided to me or my representative. Al <br /> TYPE OF SERVICE REQUESTED: IV <br /> COMMENTS: <br /> V v <br /> �'�Q �eoO� <br /> ACCEPTED BY: EMPLOYEE M 3� DATE: <br /> ASSIGNED TO: EMPLOYEE M / ZZ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ?y <br /> Fee Amount: L� Amount Paid aq c f 00 Payment Date �o g <br /> Payment Type V", Invoice# Check# (a2� Received By: <br /> EHD 48-02-025 SROf�M(CoFta <br /> REVISED 11/17/2003 J <br />