Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Ec ca (Aaa[� S� lob L-4 Log 0,5 <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ <br /> FE <br /> FACILITY NAME <br /> SITE ADDRESS \ q� C ` I ' t SIOr• r j4 t� <br /> Street Number Direction Del Street Name ` �Y� Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) 0 p <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ctv%5d.C, W�J` „c'� �$ : PHONE # EXT• <br /> t <br /> C'_ =1 � "'�)i 3 -- X03 g <br /> HOME or MAILING ADDRESS FAX # <br /> CITY S� to � rte / 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 /> 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 FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : (, ylr;(,,�,(�, �l , �1 DATE : Ito 40 f <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Q csq,(,h �h�u& t1F'�t(� � <br /> If APPLICANT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn a5 It IS available and at the Same time It ktN& e Or <br /> my representative . lr <br /> TYPE OF SERVICE REQUESTED ; tic,C <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEATH DEPARTMEN <br /> ACCEPTED BY: �� �� EMPLOYEE # : DATE : <br /> 10// <br /> �I <br /> ASSIGNED TO : J �k� Q� EMPLOYEE # : DATE : ( �J /�' <br /> Date Service Completed ( if already completed ) : SERVICE CODE : ME _ 2679 P / E . 20 ( <br /> Fee Amount : L} 5� Amount Paid Paym_/ent Date f D <br /> Payment Type Invoice # Check tooReceived By : <br /> EHD 48 -02 - 025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />