Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />qi\i,Le.._ S t`s f -411 <br />1 <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR CA FUZ( <br />Sel <br />u oi <br />1 <br />t kt , CHECK if BILLING ADDRESS <br />FACILITY NAME \ V l flu, <br />SITE ADDRESS ?-5-1 )-- <br />Street Number DIrection <br /> <br />(OLiek tr 1 i' I L h/Ci . <br /> <br />( Street Name City zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ", 1.c_ ) "-. '-i ^ <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ; kjk/Gt i 0{, e <br />1.1(_ - <br />i fl I <br />,G CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />/ hAt • <br />PHONE# _ <br />(/ ( tf ) ??lt, br5/1. <br />EXT <br />HOME or MAILING ADDRESS d -1,-7 t, <br />( 0 imr`‘otkv• 6, 1 ft" II A-1 <br />FAX# <br />CITY C.Ar.k (',,,k , (A STATE L A _ ZIP CfOL AI <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, STA7 and FEDERAL laws. <br />DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 fc 4.) <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 environmental/site 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: ( <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08