Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ERMjT <br />SERVICE REQUEST <br />EXPIRE" <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />J( <br />COMMENTS: —rO t- fI�Y C/� iv <br />`'- 'SY-'tel t!Su*Oa7D <br />kAf-14 <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />�./J ✓tJ�// <br />��L , /�� / J/ , l <br />FAX # +./ <br />( ) <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: <br />EMPLOYEE #: <br />SITE ADDRESS <br />- 6 Street Number <br />�, <br />Direction <br />J Street Name <br />city <br />Zi Code <br />HOME Or MAILING ADDRESS (If Di <br />rent from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Invoice # <br />STATE ZIP <br />PHONE #11 <br />Q ), 73 <br />EXT' <br />APN # <br />L12 <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />J( <br />COMMENTS: —rO t- fI�Y C/� iv <br />`'- 'SY-'tel t!Su*Oa7D <br />kAf-14 <br />PIIOONE# PA <br />r.. — Y41, <br />HOME Or MAILING ADDRESS <br />FAX # +./ <br />( ) <br />CITY <br />STATE ZIP , J <br />�7" <br />' 10 <br />jS <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized d ®f)*Jy T <br />acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated Id p�IV 7Y <br />activity will be billed to me or my business as identified on this form. EFgRImev <br />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 apd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 3 f / z //e <br />PROPERTY / BUSINESS OWNER . OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />U (�(5,-J1 <br />C � <br />(S <br />J( <br />COMMENTS: —rO t- fI�Y C/� iv <br />`'- 'SY-'tel t!Su*Oa7D <br />kAf-14 <br />/,� <br />i"( aPrOA45, e U7 --075r- J�,1`�VVC-t—, <br />�i�, 2b��J�d� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: o j� t <br />P / E: Z <br />Fee Amount:`G 2— <br />Amount Paid <br />% <br />Payment Date <br />Payment Type C <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 �- I ` S 7� SR FORM (Golden Rod) <br />07/17/08 <br />SON <br />