Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busirless or Property FACILITY ID# SERVICE REQUEST <br /> OWNER I OP R 5 ✓ R �f <br /> CHECK H Ru�uu:Arvwcce <br /> FAwTY NAME � <br /> S G <br /> WE ADmSS � <br /> Scram Nk m Nm C t e <br /> HOME or MAuNG ADDRESS (N DN%rent from Site Address) <br /> 5lroet N-6— <br /> CITY STATE ZIP <br /> PROW 91 ExT• APN# LAND US£MPUCATION# <br /> ckv 06 , <br /> PHONE Exr. SOS DMTMCT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK K BIWNO ADDRESS❑ <br /> BwNiiiS NAME PHONE g EXT. <br /> So 2- <br /> HOME or MAiLmG ADDRESS Lam/ FAx S I <br /> CRY `+v <br /> A STA ` 75P ' <br /> � <br /> [_ TE <br /> t <br /> WILLING ACKN WLEDGEMENT: 1. the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site an&or project specific EwR.oNMENTAL 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 JOAQUtN <br /> COUNTY Ordinance Codes,Standards, and DERV.laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERn'I BusmEss owwER❑ OPe n/MANAGER OTHER At THowzED AGENT❑ .�ry�r'1�SCT�,i (✓��`� <br /> Ij APPL1C.4.%T is not the BILLUG PARTproof of authorization to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 environmentat'site assess t <br /> information to the SAN JOAQUTN COUNTY ENviRONMENTAI HEALTH DEPARTMENT as Soon as it is available and at the same tim� <br /> provided to me or my representative. �A i <br /> TYPE OF SERVICE REDUESrm <br /> �SgN�o 3 ?AZO HEgE TNR N N COV4 <br /> T4TY <br /> MENT <br /> Accen ED BY: /� EMPLOYEE#: DATE: <br /> ASswnw TO: G\ `e EMPLOYEE#: DATE: 23 <br /> Date Service Completed (K already completed): SERVICE CODE: P,E: <br /> Fee Amount: S 2 Amount P Payment Date Zd <br /> Payment Type r� Invoice# Check# / 7 Recei By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />