Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '�)1- OOS/�-gD2- <br /> OWNER I OPERATOR �1 fr <br /> �/����, y` ,[� �{�^���y �•� �p 1�`\f ,v��CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS LJ <br /> Street Number Direction Street Name 1� City Zip Code <br /> HOME <br /> ,�or MAILING ADDRESS (if Different from lSite Address) <br /> 1 v \�O �` "���`� `"^� Street Number Street Name <br /> CITY STATE C4 ZIP /'5 3�250 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20)) s t'�) \'�) <br /> PHONE#]/ �� EXT* <br /> 605 DISTRICT LOCATION CODE <br /> w I CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR /1 <br /> n ^ ��\ CHECK If BILLING ADDRESS <br /> BUSINESS NAME C "^S PHO�tN�E# �7 ` 1 E"T' l <br /> HOME or MAILING ADDRESS FAx# <br /> CITY i ^ c o,rl STATE !?[) ZIP �jl~ <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#identified on this form. <br /> I also certify that I have prepared this applica n an t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER,, OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICRNT is not the BILLING PARTY,proofof 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: f <br /> orr1 lleFQ <br /> �(TyQ6�,' D' 7� - <br /> ACCEPTED BY: C--\ <br /> EMPLOYEE#: DATE: 10 G� 2O <br /> ASSIGNED TO: �-/` J � a EMPLOYEE#: DATE: \(DV'? 2-0 <br /> Date Service Completed (if already completed): SERVICE CODE: :52,-5 11 E: 1 <br /> Fee Amount: 1. 15—U ,O 1 Amount Paid /bz�—/ �� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-0251� ^� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 f L !?r'!/ <br />