Laserfiche WebLink
SAN JOAQOWUNTY ENVIRONMENTAL HEAftEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �S£EERVICE REQUEST# <br /> `tYOL,S is r 5100 -769 <br /> OWNER/OPERAT R <br /> 1, CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 3 V Street Number Direction r Streelt N\�am\e Zin Code <br /> HOME or MAILING ADDRESS (if Diffe=tf Site Address) <br /> Street Number Street Name <br /> CITY STA E ZIP <br /> Z'I�n� S 5 36/6 <br /> PHONE#'I EXT- APN# LAND USE APPLICATION# <br /> �2a15 D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE zip <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F ERA laws <br /> APPLICANT'S SIGNATURE: - DATE: Z 3-C) <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAwT is not the BILLING PARTY,proof of authorization 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. <br /> TYPE OF SERVICE REQUESTED: o�\ <br /> COMMENTS: <br /> A�3 020o� N <br /> OV�N SP <br /> SAN 3OAONM RNTMEN� <br /> EA TN CEPA <br /> ACCEPTED BY: O` /Y�/� EMPLOYEE#: 0321 DATE: / ?� <br /> ASSIGNED TO: I DT'C(A O� EMPLOYEE#: LfOyf DATE: r Z > 4^j <br /> Date Service Completed (if already completed): SERVICE CODE:? 5.2-.:?— <br /> PIE: -,/y <br /> Fee Amount: 410� Amount Paid 1 Payment Date 0 ,3Q <br /> Payment Type Invoice# l Check# p ( Received By: -7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />