Laserfiche WebLink
SAN'JOAC`JII OUNTY ENVIRONMFNTAL REAL70�I)LGPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> �� S� C�/rf tf/Ra?/7 / <br /> SITE ADDRESS ��� 7 (f �' r � �? '�'`/�` C,C'` TI <br /> street N0`mher Dlrection Street Name Cit Z113 Code <br /> I HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> E � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> k <br /> { ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ' CHECK If BILLING ADDRESS L=i <br /> {�AU f I Lv�LC Nc 1 L ©, /�N�i�lt1 �SSn� C, <br /> I PHONE# ExT. <br /> EuSINEssNAME N�j ✓VCt ;ZP70 <br /> FAx# <br /> HOME or MAILING ADDRESS --r- <br /> CITY l / STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HEALTii DrPARTMFNThourly charges associated with this projector <br /> ° 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 Cortes,Standard's,STA'I'D and FED ,RAL laws. <br /> APPLICAN'T'S SIGNATURE: -0 � DATE: <br /> PROPERTY I RuSINESS OWNER❑ OPERA It/MANAGER ❑ OTHER AUTHojumt)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 environmentaHsite assesstyi, nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DGI'ARTMENT as soon as it is available and at the same timelT is <br /> provided to me or my representative. ZY <br /> } TYPE OF SERVICE REQUESTED: f <br /> RECEIVE t <br /> COMMENTS: �j a �''/ + APR ¢Y <br /> jCJ_ 3 111 yl^_ +� r� 9 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> a ,p <br /> U�•sl 'KDIf-.OAS <br /> ` APPROVED BY: EMPLOYEE#: DATE: *� <br /> ASS16NEt)7O: EmPLOYEE#: DATE: <br /> Date Service CI&mpl#d (if alre completed): SERVICE CODE: 0 6-- P i E:'�"'7 � <br /> Fee Amount: Amount Paid _ Payment Date <br /> Payment Type , Invoice# Check# « � Received By: <br /> f <br /> f EHD 48-04-425 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />