Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> J <br /> FACILITY NAME <br /> I C.(ICA" <br /> SITE ADDRESSCl ee <br /> Slreel Namber Direction `-� treeTltName '"I CI � Zip Code <br /> HOME or <br /> MAILINGADDRESS (If Different fro Site Address) �r/ ✓ ✓e S�C elo <br /> L Street Number ���� Street Name <br /> � <br /> TA <br /> PHONEA EXT. APN# LAND USE APPLICATION <br /> I OV 505 -65Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE UESTO <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME G_ PHONE# 5- E.I. <br /> HOME or MAILING ADDRESSFAX# <br /> 3` / r Ave c U ( l <br /> CIN X STATE if + 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; 3"Z 3— <br /> PROPERTY I <br /> —PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER OTHER AUTHORIZED AGENT❑ 04r",L' '- <br /> IfAPPLlCANT is not e BILLING PARTY proof of authariZation to sign is required Tire <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 atfLtesame time it is <br /> provided to me or my representative. I"�^c <br /> TYPE OF SERVICE REQUESTED: yC <br /> COMMENTS: R,?3 <br /> JQ4Q <br /> ��FPAI ly <br /> �1QV� � C,Ati�� FNr <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 Z3 12 Z <br /> ASSIGNED TO: t EMPLOYEE#: DATE: 3 z3 :7 2 <br /> Date Service Completed (If Ire ycompeted): SERVICE CODE: PIE: <br /> Fee Amount: 2'UAmount Paid Payment Date 3 23 2 2 <br /> Payment Type i Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />