Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �7�'^ � T rL GAA-C-C 1_e� � Vtl S�'Sq Z7 <br /> SITE ADDRESS 4-I S VQ' '�vGl S�v1 -�{JU/ 45 '] 1 G Ir[ rj Z- <br /> Street Number Direction Street Name ,�r��7✓� Cltf�_�v t � ^ �2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) '2t I S 0 <br /> Street Number Street Name <br /> CITY /� L)' , STATE( n. ZIP /fit G <br /> PHONE#1 �7 `Exr. APN# LAND USE APPLICATION# l !i <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE) DATE: Iyl 2I 12' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPLICANT 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 andfQM"Aa9ru�time It is <br /> provided to me or my representative. _ ill .N'' <br /> TYPE OF SERVICE REQUESTED: V-QD V �iU. W� C'UyL ED <br /> COMMENTS: n n WCL ' ZUZ� <br /> i 1GWl VI t I SANdOq <br /> QU�EPC1N71OTf NTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASsIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: 03 <br /> Fee Amount: c�. '�� Amount Pal J� D Payment Date <br /> /t < <br /> Payment Type Invoice# Check# Re'ceiveld By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �� <br />