Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVVNER/OPERATOR ' <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME I <br /> iindo i NO V4 <br /> SITE ADDRESS CW M ISSAL]. S C ��umeA_kv L �1 ii <br /> ISoI Street Number Direction J`=t Street Name 7� Cl Cit 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> O Street Number Street Name <br /> CITY STATE ZIP <br /> (—A C4 15 <br /> PHONE#1 <br /> - <br /> PHONE#1 '' APN# LAND USE APPLICATION# <br /> (2.09 ) <br /> PHONE#2 Ems• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE`QU,ESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 5 bcr pk-je • ( ) <br /> CITY: ka STATE ZIP I — <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards, STATE and FEDERAL law . a <br /> PPLICANT'S SIGNATURE: DATE: <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 <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 i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> LVJ CWr1tq <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: >n <br /> EMPLOYEE#: DATE: -3 <br /> Date Service Com ted (if already completed): SERVICE CODE: P I E:14: <br /> Fee Amount t V Amount Pai /< Payment Date <br /> Payment Type Invoice# Check# 72— / 7 Received ey: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />