Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 00 0 37 53 S <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME J TI rT �jrl S� i O C e <br /> SITE ADDRESS "L rrr�J��} r <br /> Street umber Direction Street Name �i Zi CoZies <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> ;�T Cw'� Street Number Street Name <br /> CITYSTATE ZIP <br /> `3 s 5�"`f C.0 AJ v v I,, &) ¢ — ci---- LC PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR —` 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 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, Standar TE and F ERAL laws . <br /> APPLICANT'S SIGNATU DATE : C <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHERAUTHORIZED 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessmetion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is pr <br /> my representative , <br /> TYPE OF SERVICE REQUESTED : ClEe FLS � Su ' -` CLe 0 (r ) J <br /> COMMENTS : U (� p /J �X� �� { -- SAN ✓O <br /> cC.�- FNV/qQU/� <br /> HF,gCTH�pMCO�N <br /> FNl <br /> ACCEPTED BY: 2C{ r EMPLOYEE #: DATE: <br /> ASSIGNED TO : z a ri r EMPLOYEE #: DATE: 7F I C� <br /> Date Service Completed (if already completed) : ' ( � l SERVICE CODE: 0 �j P / E: LS 1 <br /> Fee Amount: �Soz U D Amount Paid lS�, Payment Date 717119 <br /> n <br /> Payment Type S �� Invoice # Check # �3g70 , Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />