Laserfiche WebLink
Y <br /> SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALTH L.PARTMENT <br />/ SERVICE REQUEST <br /> Type of Busin s or Property FACILITY ID# SERVICE REQUEST# <br /> C't�l NOL k) sP-()0779 E 75 <br /> OWN R/O RATOR <br /> CHECK If BILLING ADDRESS <br /> G <br /> FAcI TY NAME / <br /> Gr/Gi <br /> SITE ADORESS `3� / ^_y�� -S7_ <br /> Street Number Direction !/StKr_e>et Namo CI ( 21 Code <br /> HOME or MAILING ADDRESS If Different from Site Address) A <br /> OL Street Number Street Name <br /> CITY STA // ZIP <br /> PHONE#t Em APN# LAND USE APPLICATION# <br /> © 7, �OQ3 <br /> PHONE#2 EXT• BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONEE# / /EXT. <br /> HOME Or MAILING S � FA% <br /> CITY STATE ZIP <br /> �.w -7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized aguff-oT same, <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 /> 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, QFEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER Ef TOR/ ANAGER Yom- OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BI N ARTY 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. <br /> TYPE OF SERVICE REQUESTED: <br /> PAYMh <br /> COMMENTS: <br /> LIQ-* 1\)e-L") �0 coudi-1aJ DEC 0 8 2017 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN r, <br /> ACCEPTED BY: ^ EMPLOYEE#: DATE: <br /> Z <br /> ASSIGNED TO: ' Z. EMPLOYEE#: DATE: / Z /-7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: O-� <br /> Fee Amount: G U Amount Paid ) 'a- — Payment Date �, _ I <br /> Payment Type (h S yl Invoice# Check# Received By: <br /> � v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />