Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PKONE# ExT, <br /># <br />SERVICE REQUEST:L <br />OWNER/ OPERATOR <br />�� ! lr�Y • �- u �� Q /�j <br />i' CHECK If BILL�N_G ADDRESS <br />FACILITY NAME � t� <br />ACCEPTED BY: V <br />SITE ADDRESS r'J_ <br />S Stt Number <br />� <br />Direction <br />C I r6 <br />Street Narne <br />DATE: 7- 20 <br />ASSIGNED TO: n <br />Ho LW MAILING ADDf R. E 5 lif Different from Si a Address) <br />Street Number <br />EMPLOYEE M <br />Street Name <br />CrF1' t <br />STATE� ZIP <br />PHONE.ft`1j C (�_ ExT• <br />( L l % - ►.1C.� <br />APN # <br />D _ nsl <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( } <br />BOS DISTRICT f � <br />"I <br />LOCATION COPE <br />CM <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUESTOR �� i CHECK If BILLING ADDRESS <br />+ <br />BUSINESS NAME <br />PKONE# ExT, <br />HOME or MAILING ADDRESS <br />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 HEALTF[ 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 app Iicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd RAL <br />APPLICANT'S SIGNATURE: AT 0 '/- Z-L`ZZ, <br />PROPERTY/ BUSINESS OWNER❑ OPE ATOR 1 MANAGER ❑ OTHER AUTIIORILED AGENT ❑ PAYMENT <br />IJ APPLICANT is not the Bl IA'G PARTY proof of authorization to sign is required Title RECEIVED <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property lo at dlat the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environji--- llsi 12524022 <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 />SAN JOAQUIN COUNTY <br />ENVIRO <br />HEALTH DEPART ENT <br />TYPE OF SERVICE REQUESTED: <br />S <br />COMMENTS: <br />ACCEPTED BY: V <br />EMPLOYEE M <br />DATE: 7- 20 <br />ASSIGNED TO: n <br />EMPLOYEE M <br />DATE: �tLZ'Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: '- <br />i <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date .I . <br />Payment Type Invoice # <br />Check # d) <br />Received By: <br />EHD 48-02-025 SR FORM {Golden Rod} <br />REVISED 1 111 712 0 0 3 <br />