Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
S N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or�erty FACILITY ID# <br /> SERVICE REQUEST# <br /> 6[VIJE—R/—OPERATOR 5►�00`7 <br /> _t 3\J r 1- <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME '' `` -- <br /> 1 C) <br /> SITE ADDRESS 77 � <br /> �SfFeember Direction StreEt N6 e �� <br /> HOME Or MAILING ADDRESS (If Different frorn Site Address) cl Zi Code <br /> __. <br /> Street Number A <br /> CITY `, Streef Name <br /> e <br /> l S TE zip <br /> HONE#T EXT. APP/# Z D <br /> t (),►,�] 2/ —6 748 <br /> r� ^ LAND USE APPLICATION# <br /> PHONE##2 `,(O ! EXT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CON'T'RACTOR� SERVICE REQUESTOR <br /> / FREQUESTOR A- i ^ �t`�•\J Cr{ECK if BILLING QppREgg <br /> USINESS NAME +T <br /> S P NE# ExT. <br /> HOME or MAILING ADDRESS <br /> — �d ( ) O�O <br /> CITY <br /> /" STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> project acknowledge that all site and/or 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, Star -STATE and F R .laws. <br /> APPLICANT'S SIGNATGt? <br /> G�3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> //APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> Title <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: t�vo! �vu *I lu! S ,Q Jay <br /> COMP <br /> MENTS: J (/' <br /> MAK`2 z 2016 <br /> SAN`1()AQU1 N CO <br /> HE L-TH NOIUiENM[ <br /> ACCEPTED BY: ' � <br /> EMPLOYEE#: DATE; �� ' Nr <br /> ASSIGNED TO: <br /> 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed); <br /> SERVICE CODE: P/E- <br /> ("o <br /> E: <br /> Fee Amount: LQ.OD Amount Paid <br /> -���l(r,:��,c;L) Payment Date <br /> Payment Type !� Invoice# Check# (�t�4-� Received E3y; <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />