Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U Q <br /> OW R/OPERAT R <br /> /" CHECK if BILLING ADDRESS <br /> To 0 z ez <br /> FACILITY KAME <br /> SITE ADDRESS 3 v( WIL50n WQy m[k On Zo <br /> Street Number Dlrectlon I Street Name cityp Code <br /> HO E or MAILING ADDRESS (If Different from Site Address) / <br /> Street Number A C-4� 0 4Streel Name <br /> CITYSTATE ZIP <br /> i SZ <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (20 ' 17 -5 / 7 <br /> PHONE#2 E%r• BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST / <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME I ) I ' <br /> PHONE# Exr. <br /> Y <br /> HOMED AILING AD RESS I FAx# <br /> o L) i I ) <br /> CITYSTATE zip Q <br /> O <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applica In and that the work to be performed will be done in accordance with all SAN JOAQU W <br /> COUNTY Ordinance Codes,Standards,S and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: —�— Z D <br /> PROPERTY/BUSINESS OWNERR/MANAGER ❑ OTHER AUTHORIZED AGENT ElIf APPLICANT i o!the BILLING PARTY proof of authorization to sign is required Ti!!e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: ZC <br /> COMMENTS: Noll 1 <br /> 9 20'Z <br /> H�gl p�pgRrAj I1 <br /> MFNT <br /> ACCEPTED BY: I r EMPLOYEE#: DATE: J 1,o <br /> ASSIGNEDTO: t G EMPLOYEE#: DATE: , 14 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ,Q D Amount Paid �sa Payment Date <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />