Laserfiche WebLink
SAN JOAQUIN*UNTY ENVIRONMENTAL HEALTPARTMENT <br />SERVICE REQUEST <br />Type of Bu 'Hess or Pr p rty - <br />if BILLING ADDRESS <br />FACILITY ID # <br />�1�o <br />ED <br />SERVICE REQUEST # <br />.5-1112-©©%f("/3-3 <br />OWNER/ ERATO` <br />WN� � / <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />STATE 159/x/ j <br />ACCEPTED BY: <br />SITE ADDR S <br />Street <br />ber <br />Direction <br />r <br />ame <br />Date Service Completed (if already completed): <br />Z <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Amount Paid <br />Street Name <br />CITY <br />Payment Type <br />STATE zip <br />PHONE #'I Exr. <br />APN # <br />✓.- <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />69 <br />REQUESTOCHECK <br />1 C, Lu <br />if BILLING ADDRESS <br />BUSINESS NAME <br />ED <br />PH Exr. <br />HOME Or MAILING AD RESS "'� /�� <br />�J <br />WN� � / <br />FAx ) �(� „ t ^ f w <br />y-(�z/IP ((f <br />CITY */y/\ <br />STATE 159/x/ j <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 ph ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard , STA E and FEDERAL lawyl <br />APPLICANT'S SIGNATURE: DATE: �U <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT t=1 Aa— <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required t1P 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 />LAYMENT <br />COMMENTS: <br />ED <br />OCT - 7 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: (�� <br />DATE: it) 7 b p <br />ASSIGNED TO: ( ) <br />EMPLOYEE #: ` y� <br />DATE: IQ -7 1 D <br />Date Service Completed (if already completed): <br />SERVICE CODE: 17 <br />P 1 E:,)---3 p�Y <br />Fee Amount:0U <br />Amount Paid <br />'106, <br />1 Payment Date ? t D <br />Payment Type <br />Invoice # <br />Check # � O Zp <br />Received By: 14 <br />✓.- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />