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SAN JOAQ�COUNTY ENVIRONMENTAL HEALTARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW E OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAMED V <br /> ,I <br /> SITE ADDRESS E �i//j (//�/7✓� <br /> "L'3d0 S[reet Number Direction at Name <br /> HOtaEor MA ING ADDRESS (If Different from Site Address) <br /> " Street Number Street Name <br /> CITY GC STATE A <br /> ZIP/-{5v26rJ <br /> PHONE#t Enr' APN# LAND USE APPLICATION# <br /> (.20) / q3 <br /> PHONE#2 EZT' BOS DISTRICT LOCA 0 ODE <br /> (201) ti 9-0 °1 1 19 0 a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Aft/�I7.A�n�••, <br /> 1 t/ `J,� -�� � CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# ExT. <br /> a u�l2i z o }d 20 <br /> HOME Or II•ING ADD SS <br /> CITY U STATE zip v _ <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 applica ion and tha a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STT nd.FEDE law . <br /> APPLICANT'S SIGNATURE: r� DATE: / C) 27 <br /> PROPERTY I BUSINESS OWNER❑ PRA <br /> ETOR I AN OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY, Oof Of authorization to sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located t the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessml on <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is p� i'�'' <br /> my representative. •`L^ <br /> TYPE OF SERVICE REQUESTED: e Q Nov <br /> COMMENTS: �YJO <br /> ^^nc C�I�n a? EN�R0UINCOU <br /> GV1GflC�� v7 N�Acn'�PgRMfN <br /> Lr� � x/77 J <br /> ACCEPTED BY: EMPLOYEE#: DATE: //- -7 <br /> ASSIGNED TO: Dow- Lkt <br /> iO EMPLOYEE#: DATE: )) 7 - "7 <br /> Date Service Completed (if already completed): SERVICE CODE: Q� PIE:/ <br /> Fee Amount: / Amount Paid /Sa, DD Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />