SR0081690 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3(Xj SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # PHONE# EXT. 7-cI Ll SERf�VI E REQUEST # 1Z,- GI HOME or MAILING ADDRESS FAX # l,' ff, I�� OWNER / OPERATOR 'n G'♦Zj �(�V.ir I �� O,y � `/ v�unG�,��. y'� CHECK If BILLING ADDRESS CITY 7 /l. ; 2 � � " STATE (� ZIP �� �j FACILITY NAME DATE: J 7 n l C•CJ Date Service Completed (if already completed): SITE ADDRESS P I : ' �l Fee Amount: Amount Paid,- 3 oD Street Number Direction tre t Name Check # 0 City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY S i iJliiL/( L) r'— STATE r ZIP Z� PHONE #1 EXT. APN #// LAND USE APPLICATION # -400 —! 40 PHONE #2 ( ) EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR t� CHECK If BILLING ADDRESS BUSINESS NAME ;?v �L: �' PHONE# EXT. 7-cI Ll w� n c� a z c c� n L� GI HOME or MAILING ADDRESS FAX # ! DATE: ' CITY 7 /l. ; 2 � � " STATE (� ZIP C� I r � L �j BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:Avt " 1 I ^AYNIF PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ �II� /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title 3 `� AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pro pc d W',ted att 020 above site address, hereby authorize the release of any and all results, geotechnical data and/or environme�T ABo [it information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the slkl provided to me or my representative. RTL/E ) TYPE OF SERVICE REQUESTED: COMMENTS: / 0L -u 5 y`S + a,nd- c�J �.¢ W 1l t �� r• c� n L� ce.-pp rr-U v .� 'b iJJ ACCEPTED BY: EMPLOYEE #: ! DATE: ' ASSIGNED TO: EMPLOYEE #: �j DATE: J 7 n l C•CJ Date Service Completed (if already completed): SERVICE CODE: P I : ' �l Fee Amount: Amount Paid,- 3 oD Payment Date ?/ Payment Type 7 t Invoice # Check # 0 �v _�-J Received B y EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003