WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SER`'ICE REQUEST Type of Business or Property rnay-e-2- -. � BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # OD 2322- OWNER/OPERATOR rJo-vr IIS` y-,� �. r L I (J` CHECK if BILLING ADDRESS FACILITY NAME C � �i ri co>7 i'J-lar c�e�-• SITE ADDRESS Street Number o (n �� t ',� �1 treet Name y1/VCi l t C'O'L, city Zip Code HOME or MAILING ADDRESS (If Different from Site Address)/q� Street Number /An ES U L, A / • Veet Nam "1 CITY ' ^^ /2/e V Y ` `Kq Payment Type STATE ztP 9 ` 3 3 0 J PHONE#1 E%T• (2t)?) yids 8 Recei ed By: APN # LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR S CHECK If BILLING ADDRESS BUSINESS NAME PHONE # ExT. HOME Or MAILING ADDRESS FAX# CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or nuy4msiness as identified on this form. 1 also certify that I have prepare this application and that the work t0 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stan d dr, STATE and FEDE IawS. APPLICANT'S SIGNATURE: y DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 tfAPPLICANT is not the BILLING PARTY Proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si �essment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th4 hle- �L Is provided to me or my representative. `C `/'/I.. Fi. . TYPE OF SERVICE REQUESTED: +( 44' COMMENTS: 2 \„ y F 'tO,9Q �fFNl ACCEPTED By EMPLOYEE dlif DATE: ASSIGNED TO: an.e- EMPLOYEE#: g DATE: ( Z� Date Service Completed (If already completed): SERVICE CODE: �2'7) PIE: Fee Amount: 11 S -- Amount Paid Payment Date Payment Type Invoice # Check # Recei ed By: EHD 45-02-025y, '�A SR FORM (Golden Rod) REVISED 11/17/2003 'R` fu'1 r'( �aQ�. . i� 2h . C—D I k'avI Sulu )