Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S o0 7 <br /> OWNER/OPERATOR l <br /> CHECK if BILLING ADDRESS <br /> FAgLITY NAM/EE <br /> / H -fes .GL L �C�e172,✓i� t! ,oTE.���7 <br /> SITE ADDRESS <br /> Street Number Direction ��� SCreet Name �GJC�CI Zi Co�� <br /> HOME or MAILING ADDRESS (If Different fromSite Address)7_5� / /r <br /> -✓G Z /Y Street Number Street Name <br /> CITY. 14 �.C (� STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE TOR <br /> CHECK If BILLING ADDRESS <br /> BUSI SS NAME PHONE XT• <br /> HOME or MAILING ADDRESS. FAX# <br /> CITY/�i/ J� STATE ZIP/jS-J7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentofsame, <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 114e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDER S. <br /> APPLICANT'S SIGNATURE: l— DATE: <br /> PROPERTY/BUSINESS OWNER OPERATO /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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. PCA^I/ .- <br /> TYPE OF SERVICE REQUESTED: ECE1U <br /> COMMENTS: <br /> SANJOAQUIN <br /> ENVIHOMENO TNTy <br /> HEALTHpEPgR7 L <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: --7P/E: <br /> / <br /> Fee Amount: Amount Paid O Payment Date C26 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />