Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ll <br /> ' A\ <br /> CA <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADORES (If Different from Site Address) <br /> o, ,/\ } Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E7 APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> b ( o, )'LZ S - Iqqs <br /> HOME Or MAILING ADDRESS FAX# <br /> 29 6 0 „n - (,e- ( I <br /> CITY C C\' STATE ZIP C 5' �- <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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,_ d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I DATE: 1d I <br /> C <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I'APPL[cANT is not the BHL7NG PARTY proof of authorization to sign is required Tlrte <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: R , <br /> COMMENTS: el <br /> NOCT 14 <br /> Z�ZI <br /> H E�p V/NCO <br /> @9L 1. aMfNT(N� <br /> o C K NOKe <br /> ACCEPTED BY: EMPLOYEE D DATE: l-/ I <br /> ASSIGNED TO: EMPLOYEE#: �f' I DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: 52-3 P I E: I/too <br /> Fee Amon t. >-� Amount Pa Payment Date lb /v H <br /> Payment Type ><� Invoice# Check# 13 22 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />