Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME ' {(? j 2� � <br />1 J t <br />FACILITY ID # <br />SERVICE REQUEST # <br />�� n -� �-A �2 <br />fN6'�,, <br />CITY A.!]. i -F t�j STATE d ZIP 1j 3 <br />ASSIGNED TO: <br />sgm513 <br />• OWNER/ OPERATOR <br />DATE: <br />CHECK If BILLING ADDRESS ❑ <br />C�I,4 LA t..f L -f, <br />Date Service Completed (If already Completed): <br />FACILITY NAME C, ` � � ; A [' <br />J <br />-1/7 <br />T Irk <br />1 t�tp" 1�i0� 1 <br />SITE ADDRESS} <br />�d ' !St/1 <br />/ <br />U <br />V{• <br />ha/ <br />.,t .t <br />1'l ik1.UJIV41/7 <br />`- Number <br />Direction <br />Street ame <br />Invoice# <br />C <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Sm <br />PHONE#1 ExT• <br />( SIL) 3L-3- -7(� I s- <br />APN# <br />LANDUSE APPLICATION# <br />PHONE#2T• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (� <br />A CHECK If BILLING ADDRESS <br />BUSINESS NAME ' {(? j 2� � <br />1 J t <br />PHONE#) "7 _ I � • <br />HOME Or LING ADDRES <br />21 <br />FA%#�'o <br />( ) <br />fN6'�,, <br />CITY A.!]. i -F t�j STATE d ZIP 1j 3 <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, STAT FEDERAL laws. r <br />APPLICANT'S SIGNATURE: l� DATE: <br />'PROPERTY/ BUSINESS OWNER LIL OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />If APPLICANT is not the B/LLxG 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 is available and ate it is <br />provided to me or my representative. Q@.Z_ Arr <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />C,f'-fCO6C/1M?0N <br />QEP�� <br />�4T <br />ACCEPTED BY: <br />EMPLOYEE#: / _ -`�jC <br />/Q <br />DATE: <br />I- n G <br />ASSIGNED TO: <br />/ <br />-✓,T( % <br />EMPLOYEE #: <br />000 <br />DATE: <br />Date Service Completed (If already Completed): <br />SERVICE CODE: <br />Fee Amount: _ <br />U <br />Amount Paid <br />ha/ <br />Payment Date <br />Payment Type <br />Invoice# <br />Check# q '3J9-" <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />P���lo <br />S <br />