Laserfiche WebLink
SAN JIQUIN COUNTY ENVIRONMENTAL HEAL I H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> '^ CHECK if BILLING ADDRESS <br /> FACILITY NAME `M - a - o 0 <br /> SITE ADDRESS �I ACe �� <br /> Street Number Direction V t I•C• Street Name T'v�- 1 4'C1i" l Zi CoVde <br /> HOME Or MAILJA(G AD RESS (If Differ om Site Addres ) Ap 1 � ( <br /> � �'1C\ a �/`• ber rNaryhloCJ <br /> CITY �� ^ STATE ZIP <br /> PHONE 11 6 , (J 1 EXT. APN# LAND USE APPLICATION# <br /> FPHONE° � 112 �15 <br /> #2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME O n n_ p c.( 1` PH E# EXT. <br /> is <br /> HOME Or MAILING ADDRESS p 0 I �� U1 a ,/ '� (AX C. <br /> CITY —{���n STAT ZIP C�C <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 law /^ <br /> APPLICANT'S SIGNATURE: DATE: �V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site ass ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It IS available and at the same time I � o me or <br /> my representative. <br /> n If <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> H �iR uw CD <br /> TyO-pq & 4 nY <br /> ACCEPTED BY: C EMPLOYEE#: -:!-�> DATE: L- <br /> ASSIGNED TO: i f� G ( `' EMPLOYEE#: DATE: <br /> jtq <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: W0 <br /> Fee Amount: 5�Op Amount Paid �S�Oe'> Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />