Laserfiche WebLink
SAN JOAQL.,r COUNTY ENVIRONMENTAL HEALI _ APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OL>O 2-1-ZI ; <br /> OWNER/OPERATOR <br /> CHECK If BILLIN /� <br /> FACILITY NAME RECEIVED <br /> SITE ADDRESS ,/ 1 �I// 20� <br /> StreetNumber Direction '/ )Street" Name Ci! <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ENVIROMENTA NTY <br /> /9p/ street Number Street Name HEALTH DEPARTMNT <br /> CIN G O STgIF� ZIP 5 <br /> ✓J � > <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> ocI _ OGS <br /> PHONE#2 ERT' BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ CHECK If BILLING ADORES <br /> BUSINESS NAME /'D�5 ,yN Q� PHONE# _ r' <br /> HOME or MAILING ADDRES FAX# <br /> r] r r ( ) <br /> CITY Q STATE C/ ZIP Z� <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 ENvIROtNN=AL 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 thaork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT t ERAL Is s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERICI OPERATOR/N AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1fAPPLICANr 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 <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: <br /> Comm TS <br /> R%lI rv� ✓I S a.` S p lam„ <br /> IUI�� / A�Le f <br /> ACCEPTED BY: t EMPLOYEE#: DATE: L W <br /> ASSIGNED TO: w (� EMPLOYEE#: DATE: 11.. <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P I E: 6 D, <br /> Fee Amount: Z,{,O Amount Pai � Uq Payment Date <br /> Payment Type Invoice# Check# I��(P Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />