Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> RVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V enne-l sem® �- �� FU <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRES2 <br /> FACILITY NAME (/�r� / <br /> SITE ADDRESS AJ <br /> / <br /> `q `05 Street Number Direction !G Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (,2 c� ) 3(o 7 1 6// _ l70 7 P4 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) xo <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS CI <br /> BUSINESS NAME PHONE# ExT. <br /> ( <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 /> 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 laws. <br /> APPLICANT'S SIGNATURE-X �jy/ f L"�[i DATE: /v?/zGz <br /> PROPERTY/BUSINESS OWNE) OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICAN//////T 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, 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. ''L L, 0 W A 5 rE pro,0 6P 1-- -('J C-,p e-C'cf=. <br /> TYPE OF SERVICE REQUESTED: PAY <br /> v <br /> COMMENTS: <br /> DEC 2 0 2007 <br /> SAN JOAQUIN COLIN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Rc ,r�� U� EMPLOYEE#: 3 DATE: 2 7v(02 <br /> �/ <br /> ASSIGNED TO: �{ {GC(��cl U. EMPLOYEE#: 3L1'7-? DATE: 0 <br /> Date Service Completed (if already completed): SERVICE CODE: S-22 <br /> Fee Amount: !Ot Amount Paid Payment Date (�7-V 0 jU <br /> Payment Type Invoice# Check# (o Received By: <br /> EHD 48-02-025 SROR�M(olden Rod) <br /> REVISED 11/17/2003 <br />