Laserfiche WebLink
SAN JOAQU*OUNTY ENVIRONMENTAL HEALIWEPARTMENT <br />SERVICE REQUEST <br />pe of <br />Bu ss or Property <br />BUSINESS NAME ,yt�'fA <br />FACILITY ID # <br />HOME Or MAILING ADDRESS ' I � � � <br />w <br />SERVICE REQUEST # <br />CITY STATE Zip <br />DATE: � � -7� `J 3 <br />ASSIGNED TO: G , J <br />EMPLOYEE #: --7 3 $ <br />NER I��5�� nER 7 <br />}� <br />Date Service Completed (if already completed): <br />CHECK If BILLING ADDRESS <br />FACILITY NAME - 6 <br />/,. �` <br />(�Y <br />Fee Amount: �( —1 <br />SITE ADDRESS <br />Payment Date 3 <br />/�/ <br />PSn <br />Invoice # <br />Check # <br />C16 �3-/GStreetNumber <br />DirectionGX <br />t N me <br />Cit <br />Zip Code <br />HOME Or MAILING DD S (If Different from S66 Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />M#1 EXT, <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />) / —V. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUE <br />fn <br />CHECK If BILLING ADDRESS <br />REQUESTOR , ,", t *04 04 <br />BUSINESS NAME ,yt�'fA <br />PHO E,#, E' <br />HOME Or MAILING ADDRESS ' I � � � <br />w <br />FAx#�C� <br />C� /) <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 rappation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,E and FEDERAL laws. <br />7— 7 <br />APPLICANT'S SIGNATURE: / DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT W �� <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, geotechriical 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: s I 'f ro t� <br />COMMENTS: <br />RECEIVED <br />JUL 7 2001F <br />SAN JOAQUIN COUNT( <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY: I. <br />EMPLOYEE #: Z�� 2 <br />DATE: � � -7� `J 3 <br />ASSIGNED TO: G , J <br />EMPLOYEE #: --7 3 $ <br />DATE: --7 . _ 3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: i C1 <br />P I E: 'Z 3 J <br />Fee Amount: �( —1 <br />Amount Paid <br />Payment Date 3 <br />Payment Type <br />Invoice # <br />Check # <br />Received By:`)�� <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />