Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 53q� <br /> 0 /'OAPERATOR <br /> Vva_ CHECK if BILLING ADDRESS <br /> FACIL A (��{� <br /> SITE ADD E55 <br /> r Direction <br /> 0 or MA I G ADDR SS (If Different from Site Address),. <br /> �I(� -25 Street Number Street Name <br /> CITY - <br /> 1A �4 S j ZIP(/'�7r- (O <br /> / <br /> PHONE#1 VL.� E'^• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• 8DS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR !- <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> CIN 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 /> I also certify that I have prepMPE <br /> d that the work to be pe ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, DERAL laws. <br /> APPLICANT'S SIGNDATE: rr�2PROPERTY/BUSINESS OWNNAGER ❑ /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, 1, the owner or operator of the propertyLocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/s sment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t t QLic <br /> provided to me or my representative. A � <br /> TYPE OF SERVICE REQUESTED: I <br /> COMMENTS: F ✓OgQt/ 1? <br /> y�4 DFPgR 0�T7Y <br /> N _ 06 <br /> ACCEPTED BY: C EMPLOYEE#: Chi •/ DATE: `L1 <br /> ASSIGNED TO: CA V EMPLOYEE#: —7 DATE; ZA2- <br /> Date <br /> 2Date Service Completed (if already co pleted): SERVICE CODE: I OIE: <br /> Fee Amount: Amount Paid GJ a Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> VP541I�� 5 <br />