Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ./?W 6-�� S/Z D 0 71 2Z Y <br /> OWNER/OPE TOR 1 <br /> h� CHECK If BILLING ADDRESS C7 <br /> FACILITY NAME <br /> Zok - e <br /> SITE ADDRESS I C- <br /> � �L7 I <br /> r— <br /> S Tee umber Direction A Street Name J T Citv jj� "( Zio Code) <br /> HOME Or MAILING ADDRE`"' -nifferent from Site Address) <br /> GP /iE 44 �,/ / )(��r�r ` reef Number OM Street N <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 /> also certify that I have prepared this application and that the to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE a;ndFEDERA I S. <br /> APPLICANT'S SIGNATURE: DATE:_a) A3 �� y <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT is not the BILLING PARTY,/hoof 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It IS available and at the Same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: �.f E <br /> DEC 2 3 201 <br /> SAN JOAQUIN CID <br /> q NTy <br /> HEALTH UEPgRTM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �J Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: v <br /> Date Service Complete (if already completed): SERVICE CODE: 0 P/E: a <br /> Fee Amount: r}r Amount Paid L Payment Date <br /> Payment Type �, ��G� Invoice# Check# Ggi{2�B Receive By: <br /> EHD 48.02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />