Laserfiche WebLink
SAN JOAQt COUNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Ty a of Business or Property <br />FACILITY ID <br />CHECK if BILLING ADDRESS <br />SERVICE . EQUEST # <br />OWNER/ OPERATOR <br />CHECK if,I§ILLING ADDRESS <br />FACILITY NAME '�Jf ./� <br />\ <br />HOME Or MAILING ADDRESS � ✓f <br />I <br />SITE ADDR S <br />f� Street Number <br />(�i/ <br />Direction <br />l�/r,y�.((��) <br />S reeTName <br />z�IJP G/ ;-()5 <br />\^j�� <br />x.11 U •iF <br />3+')C, <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />,' <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1��' `F �� , p ExT• APN # <br />( 0) LI/ /7{ <br />LAND U APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRAC R / SERVICE RE UESTOR <br />REQUESTOREy <br />( 1(k-rn C. y <br />I I c/ <br />(/j <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />� , <br />1 <br />IAL V <br />PHON <br />1 ExT' <br />-037 <br />HOME Or MAILING ADDRESS � ✓f <br />I <br />F � ) <br />4 t - 1 — 13 f-2 <br />CITY f" STATE A <br />z�IJP G/ ;-()5 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned prope ' r business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENrAI TH 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 peormed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FEDERAL laws <br />APPLICANT'S SIGNATURE: 0MA." U t L,r%v DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTH\1required <br />NT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to siTitle <br />AUTHORIZATION TO RELEASE IN�F'ORMATION: When applicable, I, thr operator of the property located at the <br />above site address, hereby authorize the releasq-of any and all results, geoteta and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRrAENTAL HEALTH DEPARTMENs it is available and at the same time it is <br />provided to me or my representative. f <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />m <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATX-, <br />Date Service Completed (if already co pleted): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />, <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 ( V' FOR4 (Glen Rod) <br />REVISED 11/17/2003 \- <br />