Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business1 or Property FACILITY ID# SERVICE REQUEST# <br /> � SU (`iz MMWs✓2- _F <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS14A \ <br /> �� LC dl p152 v <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) C�yC)2, OSv1PW^e -, <br /> Street Number Street Name <br /> CITY `� 1 STATE ZIP C? I 9 <br /> PHONE#1 F D ExT• APN# LAND USE APPLICATION# <br /> (2(1) L\ 6) !� <br /> PHONE#T EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ 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 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 <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, STA and F DERAL laws. <br /> APPLICANT'S SIGNATURE: c DATE: <br /> 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 same time it is <br /> provided to me or my representative. Pio <br /> TYPE OF SERVICE REQUESTED: 1/)3�� (� til CEI <br /> COMMENTS: Fro 4-009202, <br /> JOAQU <br /> "no <br /> OV C UNC <br /> N DEPART NT <br /> ACCEPTED BY: ((,�, EMPLOYEE#: DATE: 6 1 <br /> � <br /> ASSIGNED TO: shewif- Vu I OctI EMPLOYEE#: DATE: 2 � ' <br /> Date Service Completed (if already completed): fC SERVICE CODE: P 1 E: <br /> Fee Amount: �_ Amount Pa' �e d l� Payment Date <br /> Payment Type 7kInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />