Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Doi, z-Z- �I <br /> OWNER/OPERATOR <br /> �"' CHECK if BILLING ADDRESS <br /> C-I f <br /> FACILITY NAME l �1 1 c <br /> SITE ADDRESS /J6 ` S3 <br /> Street Nuer Direction I I Street Name �y QCi �z10 Cod <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 <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 perfonned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar&4 STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: d <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> if APPL/(:INT 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. A <br /> TYPE OF SERVICE REQUESTED: S V 1 pry Y <br /> COMMENTS: <br /> Jti <br /> SAI y JO t 0? 2020 <br /> FNVtAQV/N <br /> N�CTy D pMEi yTANTy <br /> ACCEPTED BY: EMPLOYEE#: DATE: -- T <br /> ASSIGNED TO: —A \^ EMPLOYEE#: DATE: -1 <br /> Date Service Completed (if already completed): SERVICE CODE: V I P I E: <br /> Fee Amount: j 5 Z _ Amount Pai (� Payment Date 7 Z 2U <br /> Payment Type Invoice# Check# Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />