Laserfiche WebLink
:f <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of business or Property FACILITY ID# SERVICE REQUEST# <br /> Tacc� L'4� 2 - 7i5 P <br /> OWNER/OPERATOR <br /> a pN CHECK if BILLING ADDRESS L.I <br /> FACI <br /> (Si7.&ATuaa�c= <br /> mbar Direction 5 re Zb Coate <br /> HOME Or MAILING ADDR S (If Different from Site Address) A- e ama <br /> QV `b Sheet Number L Sinal Name I <br /> C ,-76 ,�-2-7 // STATE zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ext. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHOPIE# 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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: f Qti'll4 \1q-fo3— DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required 7iNc <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 or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> CmIr,IENTS: RECEIVED <br /> FEB 13 2015 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> S <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: PIE: D `� <br /> Fee Amount: Amount Paid 2.. Payment D to <br /> Payment Type Invoice# Check# Received B <br /> EHD 4d-02-025 <br /> 07/17/08 SR FORM (Golden Roti) <br />