Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L/EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M F Pc,( F-Prwu3oof25 —4FttIy17 <br /> OWNER/OPERATOR n <br /> 0 CHECK If BILLING ADDRESS LI <br /> FACILITY NAME <br /> --ICCS LlallrT <br /> SITE ADDRESS 157 er Direction Street Name C �� h/ Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP _ <br /> S 77d / f� 5` <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> f1F302 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r� Y ) CHECK If BILLING ADDRESS <br /> BUSINESS NAME --- PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ' vo7 Lt a ? ( ) <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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: i s �/� ,� �1,��- DATE: <br /> -�1-L�— r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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 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 to me o <br /> my representative. nn <br /> TYPE OF SERVICE REQUESTED: �(hC/ <j � <br /> COMMENTS: <br /> N0 (0►MrVii �� -ro��,y. MAY 0 32016 <br /> SAN OAQtjtN COUNTY <br /> EN HEALr HOA#ENT-4L <br /> N DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 <br /> ASSIGNED TO: Dr EMPLOYEE#: DATE: <br /> Date Service Cons (if already completed): SERVICE CODE: Sof I P/E: ((Pp�j <br /> Fee Amount: , f 36-CD Amount Paid Payment Date <br /> // <br /> Payment Type Invoice# Check# Received By., ,, T. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />