Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S//E��RVIICC/E REQUEST# <br /> V <br /> pS l <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS 13 <br /> FACILITY NAME <br /> r,, <br /> SITE ADDRESS M Un+h ��� -, ,� ✓�]�'�I C-�1,r, ✓ 2- J (O <br /> 2Z? L) Street Number Direction Street Name City Zip 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 /> ( 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �VAr, CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> l,U 1./ 1 j�'I <br /> HOME or MAILING ADDRESS 'A FAX# <br /> 7 �Z t'I rnUr1�hC . Y�� (G ) to 2- 7 to Z I <br /> CITY I/h STATE UN ZIP / S7 Z 0 r <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 HFALTH 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandarcls,STATE and FF At.IawS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER Cl OTHER AUTHORIZED ACENT❑ <br /> !f.-1 PPLK'ANT is 1101 the BILLING PA ITE',proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 COUN'rY 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: <br /> COMMENTS: JA At <br /> z 20, <br /> JO QUI <br /> HF�TH p p fE COUNTY <br /> ACCEPTED BY: ( c EMPLOYEE#: DATE: , ��J 1 2 1 <br /> ASSIGNED TO: '` EMPLOYEE#: DATE: 1 12C) 2L` <br /> Date Service Completed (if already completed): SERVICE CODE: /1 Gj ` 131 E: <br /> Fee Amount: 1rJ Amount Paid Payment Date n. <br /> 2 <br /> Payment Type C.__ Invoice# Check# Received By:��D <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />