Laserfiche WebLink
SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID## SERVICE REQUEST# <br /> rIT- <br /> OWNER/OPERATOR ` <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 2 , OS , � � y T <br /> Street Number Direction Street Name C ity 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 /> (`off) 1 ` ' 5ocs ��C7 <br /> PHONE#2 EXT• BOS DISTRICT. CATCODE <br /> ( ) ave1FC?5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEi PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY E 5(—C`C� ,, STATE fl� ZIP 9513` 2—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 <br /> or 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,STAT F E laws. <br /> APPLICANT'S SIGNATURE: DATE: Z 9 — ),7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a©\1lP..CI\e%r ,C`` <br /> If APPLICANT is not the BILGING PARTY,proof of authorization to sign is required Title(:i PeAroA i C,t„S <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 an the same time it is <br /> provided to me or my representative. MAir <br /> TYPE OF SERVICE REQUESTED: EIVE <br /> COMMENTS: SEP O C 2017 <br /> SM JOAQUIN COU <br /> HF -H EPq-Wr NT, <br /> ACCEPTED BY: 'j'� ^\u C � EMPLOYEE#: 2 DATE:9 [-- <br /> ASSIGNED TO: 44 �u EMPLOYEE#: *ac> DATE: lclhVt J <br /> Date Service Completed (if already completed): SERVICE CODE: 61,01 PIE: <br /> Fee Amount: Amount Pa Payment Date <br /> Payment Type C Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />