SR0080823 - Laserfiche WebLink

Home Browse Search

MIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, ��yy SERVICE REQUEST �..r PI D Type of Business or Property FACILITY ID # 5 OWNER / OPERATOR /' u AJ I V 1\ 1 .� E VICE EST # D 2-� CHECK If BILLING ADDRESS FACILITY NAME l , HOME or MAILING ADDRE FAX # SITE ADDRESS-� U Gtreet Number Direction S Street Name EMPLOYEE #: r Ci DATE: Zi Code HOME Or MAILING ADDRESS (If Different from iteA�dore s) GC. 0 " Street Number Street Name CITY STATE ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # Fee Amount: PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTORC `� :2 6) � CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRE FAX # CITY J STATE ZIP BILL. PLN WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackn led{ _fi at 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 rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ATE and FEDERAL laws APPLICANT'S SIGNATURE: � DATE: l PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ _BZWA)U., r 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: r r COMMENTS: /� ( x -a ► Y) M 1 \ �� 71Co {(f lei 'to ' l q t 6�c A?_ (n' C ll -f� I nc-�� -- 2� c�a� —o ��k' �- ��aS' �C. ACCEPTED BY: EMPLOYEE #: T/I i DATE: ASSIGNED T0: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: , PIE: Fee Amount: Amount Paid �� Payment Date 2�P l l Payment Ty p Invoice # Check # Received By';_a� - . meiv [- RECEIVED RECEIVED EHD 48-02-025 07/17/08 JUN 2 b 2019 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PEdMIT EXPIRED SR FORM (Golden Rod) c0 ttIv4c