Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> fi�s 3 [A 51 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESSO <br /> J i v�eV.& CA <br /> FACILITY NAME <br /> SITE ADDRESS I V W ►� ! l � " a7 4s C� <br /> Street Number Direction Street Name Clt Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE #1 <br /> EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 ExT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Iota to <br /> BUSINESS NAME r PHONE # Ems' <br /> l,L�z t�� , W 01 i g <br /> HOME or MAILING ADDR S FAX # <br /> b c � uu ( ) <br /> CITYC' �� � D CA <br /> ( � STATE ZIP [j 'r - It <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 or <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 Codes, Standards, STATE and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : � � ,wV , DATES�. /�� �( <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT is OLU,.w; S ( Q_l(LE I <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to me or <br /> my representative . 43IVILW <br /> TYPE OF SERVICE REQUESTED : V t Lt, ( o� (�C+uN ' l I <br /> COMMENTS: <br /> JVe <br /> UN 16 2021 <br /> 1+! N N I RJOAON I N COIN <br /> 4'VEALTy 0E EWA <br /> ACCEPTED BY: \ �� , EMPLOYEE #: DATE: JP rAlEAI <br /> �J <br /> ASSIGNED TO : J„ „ ���1 ��� EMPLOYEE # : DATE : i7 V I <br /> Date Service Completed (if/already completed) : SERVICE CODE: P I E: Z <br /> Fee Amount co Amount Paid 4&, , A) Payment Date <br /> Payment Type Invoice # Check # 124 4 ; 6 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />