Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> t� t SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r„ OWN R/OPEI OR <br /> c✓�` r_ a Y 7(� e�t.�V G� CHECK if BILLING ADDRESS <br /> FACILITY NAMES <br /> SITE ADDRESS ��fJ/V'� S I lI/ /� <br /> Strt Number Dlreetlon C�` �/ 'gI t Name � it n Zi Code <br /> HOME or MAILING ADDRES-IS, (if <br /> �Diifferre-nt from Site Address) <br /> 25�s \ t ' VJ • LI i ' Stmet Number Street Name <br /> CITY �ySTATE zip ^ <br /> e �G . "L <br /> PHONE#'I EXT' APN# LAND USE APPLICATION# <br /> (2�9 ) x[20- z3SO <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORM//�� O ,(t <br /> 1 1 a , 0.QJSQr t � Q(y�� l(� CHECK If BILLING ADDRESS <br /> V <br /> BUSINESS NAME PHONE# EXT. <br /> Los �a5 ectl es. <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 /> 1 also certify that t have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standars, TATE and F ERAL laws. <br /> APPLICANT'S SIGNATURE: -GU Ke l e Ck L V(6 DATE: <br /> ROPERTY/BUSINESS OWN ER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPUCANTis not the BLLLLVGPARrr 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> AA, <br /> ACCEPTED BY: WI� S <br /> EMPLOYEE#: {-/ DATE: ( 2 T <br /> ASSIGNED TO: ` EMPLOYEE#: DATE: ) i1 2?— <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: U Amount Paid _ Payment Date 12y 2y v <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 o5q -1 q` <br /> V `I S <br />