Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '57ofT s�R v� :« �,� SP ti <br /> OWNER/OPERATOR <br /> /V a-)7 <br /> c� c1� CHECK If BILLING ADDRESS F-1 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Naine CRY ZI Code <br /> NOME 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 /> ✓�j� �`� d CHECK If BILLING ADDRESS <br /> BUSINESS NAME '• PHO E# ExT. <br /> or�y�s .�.�of•r sRv� <br /> HOME Or MAILING ADDRESS FAX# <br /> ✓rte /y1 6SgRR GSz ( ) <br /> CITY A� 7-9,f'4 C YrY STATE ZIP rt <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/"AGER 13 OTHER AUTHORizEDAGENT❑ <br /> IfAPP61cANT 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 andAt the same time it is <br /> provided to me or my representative. IIll A <br /> TYPE OF SERVICE REQUESTED: V IAWA co s I C <br /> COMMENTS: 406 <br /> %'10q 0 41010 <br /> HRCT OFp 7,,qt <br /> ggrMeNr <br /> ACCEPTED BY: WILAra l \ EMPLOYEE#: DATE: <br /> 19 •?f <br /> ASSIGNED TO: V( Cor EMPLOYEE#: DDD DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> Fee Amount: f �'d Amount Pa'�f Payment Date 2� <br /> Payment Type Invoice# Check# 112-0gZ13 I Rec ved By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />