Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> (_-71,,( � � _ / no � CHECK if BILLING ADDRE55O <br /> FACILITY NAME (� �i�(�,/ <br /> /nl�r CG Pr °n <br /> SITE ADDRESS a�J y U S' /� r UJ C/,52 9 <br /> Streel Number Direction ,'( Street Name / ✓ Cit Zi Cotl¢ <br /> HOME or MAILING ADDRESS (If Differ nt.fromAddress) <br /> Site Street Number Street Name <br /> CITY G ) n r^� STATE ZIP Z <br /> PHONE#t 7X` Ems. APN# LAND USE APPLICATION# <br /> (e5v 98 Sz 9 z <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 7 �/ ✓ PE# E <br /> /lIQ✓ a er;1-7 HONro ,�95 ? �Z <br /> HOME or ADDRESS / � � FAX# ) <br /> CIN0 G 6� - $TATE/1/I ZIP �7 L <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 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards, STATE and FERE aWS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NA ER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLiCANTis not the BILLING PARTY proofofauthorization to sign is required Title <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 to 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. c <br /> TYPE OF SERVICE REQUESTED: C - <br /> COMMENTS: NOV3p IveD <br /> �1Ql�J cOVL✓�� %� a ?0 <br /> v oYO <br /> ACCEPTED BY: �1 EMPLOYEE#: DATE: II 3V 2(J <br /> ASSIGNED TO: - EMPLOYEE#: DATE: I so ZD <br /> Date Service Completed (if already completed): SERVICE CODE: PA: <br /> : <br /> Fee Amount: S 2 Amount PaidI�'a i Payment Date 3�1 �1 A <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />