Laserfiche WebLink
SAN JOAQU N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#: <br /> aw()9 :1seooda/ 0 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> .y <br /> SIT SS <br /> 190S �LnfLt/D afl7CLQ ✓ -)�• <br /> Street Number Direction MEWStreet Name cityLtode <br /> KM'MF Or MAILING ADDRESS (If Different from Site Address) <br /> ' Street Number Street Name <br /> CITY STATE zip . . <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> A� '�t CHECK if BILLING ADDRESS <br /> BUSINESS NAME / PHONE# E" , <br /> HOME Or AILINP ADDRE / FAX# <br /> CITY O J STATE ZIP <br /> BILLING ACKNOWL DGEMENT: 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 projector <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,STAT�DERAL aws. <br /> APPLICANT'S SIGNAT , DATE: (G y! <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /f APPLICANT is not the BiLLlNGPARTP 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 t0 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: R EC E I V F_L') <br /> UN 1 0 2010 <br /> DN1P <br /> NI <br /> ACCEPTED BY: EMPLOYEE#: DA <br /> ASSIGNED TO: EMPLOYEE#: y!? DATE: <br /> rea <br /> Date Service Compfeted (if aldy completed): SERwCECODEJJ PIE: oZ <br /> Fee Amount: cq) Amount Paid 3 Payment Date p O <br /> Payment Type invoice# Check# .s 2A b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />