Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prope FACILITY ID# SERVICE REQUEST# <br /> ( IE <br /> OWNER/OPER TOR t- <br /> t FS CHECK If BILLING ADDRESS <br /> FACILITY NAME ^ <br /> SITE ADDRESS er O�rC At�/� N� ` �SZ() I <br /> 2\\'3 Street Number Direction • `-1 ( I C - � Sir(e¢[Nama Y ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 �r Exr. APN# LAND USE APPLICATION If <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext <br /> i ) <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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST nd FE ERA�s. <br /> APPLICANT'S SIGNATURE: DATE: X Z 2/ Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER 11 OTHER AUTHORIZED AGENT 13 <br /> IfAPPLicANT is not 117E BILLING PARTY Proof of authorization to sign is required Tiri pw <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the prop *e11e 4 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirommenta <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and atp{�e/�ame tim <br /> provided to me or my representative. bt T <br /> TYPE OF SERVICE REQUESTED: EftJOAQUiN <br /> COMMENTS: <br /> 7-0 &'9y 7/j,/ e"Ll'P.e �' <br /> 5t ' 'Z . /� E —'�" �— KEG! T <br /> ACCEPTED BY S EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: f� <br /> Fee Amount11 S;-2— 1 Amount Paid a r Payment Date V rel I'�I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> ��� 538m24 <br />