Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID _# SERVICE REQUEST # <br />OWNER OPERATOR // , <br />BUSINESS NAME <br />CHECK If BILLING ADDRESS❑ <br />FAOLRY NAME <br />En. <br />61soo <br />HOME Or MAILING ADDRESSFAx# <br />ger <br />SITE ADDRESS <br />b BtnH Nu Mr DI I <br />!> <br />V n <br />yes-9�s� <br />CITY va• Ceras <br />` <br />`J C <br />95a�Caa <br />ZI <br />HOME Or MAILING ADDRESS (N Different from Site Address) <br />9treat Num Ear <br />ASSIGNED TO: <br />Street Name <br />CITY <br />DATE: <br />STATE ZIP <br />PHONE #1 ET. <br />( ) <br />APN # <br />PIE: <br />LAND USE APPLICATION# <br />PHONER <br />C) S (� <br />(Check# <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR M Op / - �y+aotTG/n <br />CHECK If IL IN DRE <br />BUSINESS NAME <br />PHONE # <br />a <br />En. <br />61soo <br />HOME Or MAILING ADDRESSFAx# <br />ger <br />(aoq) <br />yes-9�s� <br />CITY va• Ceras <br />STATE R <br />ZIP (�X30 <br />]BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that allsite 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 th the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ <br />If APPLICANT !s not the <br />/ DATE: <br />f <br />MANAGER ❑ OTHER AUTHORIZED AGENIJ9 Sror�c�Vaor <br />NTY proof of authorization to sign is required Tilt, <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 Is available and at the Same time It is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 617;�j- <br />COMMENTS: <br />J <br />� 1�0 <br />MAy 1 <br />GOO <br />6PN d0 goNM R pj N <br />EP1HO-V <br />ACCEPTED BY: <br />EMPLOYEE #:c�2 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: hb <br />DATE: <br />Date Service Completed (If already Completed): <br />SERhCEE CODE: <br />PIE: <br />Fee Amount: Q CJS <br />Amount Paid <br />C) S (� <br />(Check# <br />Payment Date S <br />Payment Type ✓�- <br />Invoice# <br />7Lt� <br />RecelvedBy:� <br />EHD48-02-025 SR FORM (Golden Rod) <br />REVISED 11/172003 <br />