Laserfiche WebLink
SAN JOAQUTA COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5�0071u�� � <br /> OWNER/OP TO <br /> -O CHECK If BILLING ADDRESS13 <br /> FA TY NAME. <br /> _V Irte 1 0 <br /> $ITE ADDRESS` ' Ce , 1 pn� ��� s .�O L, (�( o. 5Z� <br /> 7/ 7 ba Street Number DIrecUon v - "t Street Name CI " ` Zip Code <br /> HOME or MAILING 1A'DDRES ((f Differennit from Site Address) <br /> V W , L Street Number Street Name <br /> CITY STATE ZIP <br /> GG k } 0 COLI _Sz o 6 <br /> PHONE#1 ENT' APN# LAND USE APPLICATION# <br /> ( ) w 6 V <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE UESTOR f I ` <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME , / PHONE# /^r ExT. <br /> b <br /> HOME or MAILING ADDRESS FAx It <br /> 27 OS- W ( ) <br /> CITY STATE ZIP or 5 O� <br /> BILLING ACKNOWLEDGEMENT: 1, 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: �� �( �rJJ DATE: ) /Cl �Q/-7 <br /> PROPERTY/BUSINESS OWNE5 OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT ❑ <br /> If/APPLICANT is of the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> t0 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: <br /> COMMENTS: �.✓q/ O <br /> D c-- oN,Nco�» <br /> yOFpgR�q�NfY <br /> ACCEPTED BY: �C EMPLOYEE#: DATE: <br /> ASSIGNED TO: j EMPLOYEE#: DATE: 3. 'O- <br /> Date Service Completed (if already completed): 7 SERVICE CODE: U I PI/E: <br /> Fee Amount: Amount Pahw 3 D Payment Date 3/ <br /> r <br /> Payment Type 0 Invoice# Check# Recel4ed By: J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />