Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST fm(L� 311'-� <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ��d Q� D <br /> Street NOmher D,.,,.. Street Na //e ` CI Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr' APN# LAND USE APPLICATION# <br /> ( ] <br /> PHONE#2 E:r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Q CHECK If BILLING ADDRESS <br /> BUSINESS N / PHONE# , Exr. <br /> 0 <br /> HOME Or MAILING AD RESS FAX# <br /> ( ) <br /> nY IW STATELP ;?rP <br /> BI"G ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTmFNT hourly charges associated with this project <br /> or activity will be billed to we or my business as identified on this form. <br /> 1 also certify that I have prepared this applicatig nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> RATOR/ ' CER ❑ OTHER AUTHORIZED AGENT <br /> PROPERTY/BUSINESS OWNER❑ OPEI� <br /> I,fAPPLICANT is not the BILLING P .I1rdef of authorization to Sign i5 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 environntental/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 SERVICEREQUESTED: <br /> COMMENTS: SWQ <br /> j 1 s7 ( (G//I �Gi„ �r,��r �l// (( hIHA a SIC <br /> /�Qd/G�/ � �aOgAfopQL/ ZO?� <br /> �J "f&qL ONM COU <br /> ACCEPTEDBY: EMPLOYEE#: DATE: ? /. <br /> ASSIGNED TO: EMPLOYEE#: t DATE: J <br /> Date Service Com eted (If already Completed): SERVICE CODE: - Z P Ile.. <br /> Fee Amount: 3CO Amount Pald 3 v� Payment Date 31N 3 2 <br /> Payment Type Invoice# Check# /ZcD I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 95 pl pIR��(���� � p�3(to Z�Llo <br /> I'° Y r <br />