Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �r�h'l;1 i OBJ �r A 0 7 2 1-2 S 40 0 9 ZC-1 v?t- <br /> OWNER/OPERAT Rdzli�f-11-) <br /> CHECK If BILLING ADDRESS❑ortw//�a <br /> FACILITY NAME <br /> SITE ADDRESS 7 y,'' � �/� <br /> 1 Street Number DAIL � Street Name cityZi Code <br /> HOME or <br /> MAILING ADDRESS/yDiffe//ee��►►t from//Site 7e, <br /> ss) [�/�f <br /> /L��1� Street Number ����/' �S"treet � <br /> CITY ' STATE CSCr� ZIP S'z�O/ 7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> o � -J/'R)— 65 3 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> /REQUESTOR / I�n/ . CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME L r /� PH N � jEXT. <br /> HOME Or MAILING ADT S G FAX#Ire <br /> G� <br /> CITY STATE r 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 th ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TE and FI L <br /> , T s. <br /> /,:ZA1 <br /> APPLICANT'S SIGNATURE: G� r DATE: CJ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ER AUTIIORIZED 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 <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. <br /> TYPE OF SERVICE REQUESTED: AY <br /> COMMENTS: <br /> C �-- � S Cotes' u � �� � b LA s 20 A�6 0, <br /> g,V J0,4 20 <br /> eNV/'� Upy CO <br /> h�'gCTy 0O�pgENTqUMTy <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: o <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />