Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 1 Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Na rv) <br /> OWNER/OPERATOR <br /> �/� CHECK if BILLING ADDRESS <br /> �/ r <br /> FACILITY NAME ` t �1 S <br /> /SIT�E]ADDRESS C�'`J�6 S��'�i('J <br /> {1'G -��75St�t Number Direction Street Name �© CR ZI Cod <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Z - A — Street Number `' Street Name �U <br /> CITY STATE ZIP <br /> PHONE#t E7APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HomE or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOW E ENT: 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 <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 Codes,Standards,STATE arid FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: '�'^"es— <br /> PROPERTY/ <br /> es--PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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 salve time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C , 41% <br /> COMMENTS: <br /> sq�JOCq,� 19 <br /> 1?01?1 <br /> 14 7REpMFiy�UN7}. <br /> ART�F�'T <br /> 14 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: zf EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE.CODE: too I PIE: <br /> Fee Amount: L�2 r Amount Pao Is� 06 <br /> Payment Date 4 2 <br /> Payment Type Invoice# Check# Recei�ed By: <br /> EHD 48-02-025 SR FORM(Gaiden Rod) <br /> REVISED 11/17/2003 <br /> X6003\1 S <br />