Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA no��3 I� -, <br /> OWNER/OPERATE[ — <br /> `0- CHECK if BILLING ADDRESS❑ <br /> FACILrrY NAME l �L <br /> SITE ADDRESS <br /> Street Number I DIrectlon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ; r '�r <br /> c F'! <br /> Street Number i Street Name <br /> CITY STAVE ZIP <br /> PHONE#'I EXT, ��PN# LAND USE APPLICATION# <br /> �)oco l 15-_S�6 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> � l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> C= <br /> V` c It <br /> BUSINESS NAME PHONE# ExT. <br /> Yo �r <br /> �_0 1 r <br /> HOME or MAILING ADDRES FAx# <br /> CITY: ' ., STA`Fp T'� ZIP cG,�'2 0 <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 HEALTEI DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as ide fed on this form. <br /> I also certify that I have prepared this application aid t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: QSSI l jn. d <br /> PROPERTY t BUSINESS OWNERO OPERATO MANAGER ❑ 01-1'1ER AUTHORIZER AGENT❑ <br /> I,f fAPPLIC.41VT is not the BILLING PARTY,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 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: G NT <br /> COMMENTS: D <br /> SAN 112020 <br /> Ham'1/1 01V NTUN�` <br /> MENt <br /> At <br /> ACCEPTED BY: f o EMPLOYEE#: r) DATE: '� <br /> ASSIGNED TO: V ` EMPLOYEE M V� DATE: I y9 <br /> Date Service ompleted (if already completed): SERVICE CODE: PIE: l�U <br /> Fee Amou � �Jj 1 -1Amount Paid zf� f Payment Date O ZZ <br /> Jar <br /> Payment Type Invoice# f Check# Recei ed By; <br /> EHD 48-02-025 12 ���` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 111 <br />