Laserfiche WebLink
I 1k I <br />SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTE ;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME Or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE ZIP L !:C <br />JUN 16 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: MR <br />EMPLOYEE #: <br />tl <br />V <br />OWNER/ OPERATOR <br />ASSIGNED TO: <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESOU <br />Date S@NICe Completed (If already completed): <br />SERVICE CODE: -,r'L L <br />P I E: L <br />FA ITY ESIT <br />Payment Date r <br />S <br />/ !I la(v"� <br />�I nco <br />Check # <br />Received By: <br />\6 k,DDRE <br />�S treat Number <br />it c[i n <br />I Street <br />Na e <br />C <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE <br />ET' <br />APN # <br />LAND USE APPLICATION # <br />`#1 <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />rv?) -66q <br />3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if §161-INg AD RES <br />BUSINESS NAME <br />P NE# EaT' <br />HOME Or MAILING ADDRESS <br />Fri,# <br />i2 ) <br />CITY STATE ZIP L !:C <br />JUN 16 2011 <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 t be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S T Tnd FEDERAL law V <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTO� <br />/fAPPLLCANT is not the BILLING PARTY proof of authorization to sign is required Tide <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: L <br />COMMENTS:' /!„D <br />PAYMENT <br />V L%t{J <br />RECEIVED <br />JUN 16 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: MR <br />EMPLOYEE #: <br />tl <br />V <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date S@NICe Completed (If already completed): <br />SERVICE CODE: -,r'L L <br />P I E: L <br />Fee Amount:rr <br />Amount Paid <br />Payment Date r <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Got n Rod) <br />REVISED 11/17/2003 <br />