Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> ,u CHECKif BILLING ADDRESS <br /> FACILITY NAME <br /> f <br /> SITE ADDRESS <br /> Street Number Direction �/\CN S[reet Name CII Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name t�V <br /> CITY( STATE ZIP "(�yam` t s <br /> PHONE#1 Err. APN# LAND USE APPLICATION# `' <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> P <br /> i CHECK If BILLING ADORESSE] <br /> BUSINESS NAME " ' <br /> E T. <br /> � • II o ) CO 2S6 <br /> HOME or MAILING ADDRESS ' ' - FAx# <br /> fi ( ) <br /> CITY C..I'' ,t._ _ STATE (` Pr 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 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:ZIDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IJAPPLiCAmTis not theStcuNGPARTY 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available and at the same time it IS <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O� I commgm �. <br /> COMMENTS: <br /> APR <br /> 110 <br /> Ty EPgR�4 <br /> ACCEPTED BY: I EMPLOYEE M DATE: 1 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: IZ n' <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount: t Amount Paid / do I <br /> Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />