SR0084282 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING AD S ERVICE REQUEST # 1 CITY 1 STATE ZIP 8 `SANTO S46 ut\Qp 4 ;` 3 � OWNER / OPERATOR 1 CHECK if BILLING ADDRESS T ACCEPTED BY: �— 1.��_ / Ilk DATE: / a� TMENT FACILITY NAME EMPLOYEE #: DATE: � d8 a SITE ADDRESS I SERVICE CODE: / P i E: Amount Paid G'Ed Street Number Ddr l n 4i Street Name Cy ZIp Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Type CI Invoice # Pc) e) ox Street Number Street Name CITYe,, wpo STATE ZIP PHONE #1 EXT• APN #LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT �{ LCODE OCATION CONTRACTOR / SERVICE REQUESTOR REQUESTORLr CG ' ��YiGC , CHECK if BILLING ADDRESS WW BUSINESS NAME PHONE ExT. HOME or MAILING AD S FAX# 1 CITY 1 STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDER. L APPLICANT'S SIGNATURE: 2 — DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1:1 If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information 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 my representative. TYPE OF SERVICE REQUESTED: 1/ 8� I t 1 �C�. -t f O j� 't S '� (L mwi k' o od leqal h,qe (;r '11LA COMMENTS: J�dP n }, Fy e064 q nd t'e c1; fd C, :, Y-4 yt t e �D p t1rt�"''ri I IV IVF ' p e��oo�eG'' Solas r!U (,. CALL(209)953-7697 1 8 `SANTO FOR INSPECTION. 24-HOUR NOTICE H FN�/R0�/NCO� NMF N REQUIRED. T ACCEPTED BY: �— 1.��_ / Ilk DATE: / a� TMENT ASSIGNED TO: TZ EMPLOYEE #: DATE: � d8 a Date Service Completed (if already completed): SERVICE CODE: / P i E: Fee Amount:I s a Amount Paid I / Payment Date 9128124 Payment Type CI Invoice # 13o259 (D(-o Received By: EHD 48-02-025 REVISED 11/17/2003 RV SR FORM (Golden Rod) o�tr.