WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property L L CES FACILITY ID # r 6 ..Y, C /, SERVICE REQUEST # 0Di 521 Ld OWNER / OPERATOR AV �v' CHECK If BILLING ADDRESSEJ FACILITY NAME Exr• HOME Or MAILING ADDRESS ^] SITE ADDRESS )01' 011 Street Number Direction I'lt �Ireet Name J Cit p -f Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number CITY Street Name CITY Payment Type a STATE ZIP PHONE#t Esr, Check # 8 �l APN# LAND USE APPLICATION# PHONE#2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR L L CES COMMENTS: m t r� . _'� .�/I1 ' ^ � ��/� 1 ViVIV SOS o TO r 6 ..Y, C /, ACCEPTED BY: CHECK If BILLING ADDRESS BUSINESS NAME EMPLOYEE#: PHONE # Exr• HOME Or MAILING ADDRESS ^] EMPLOYEE #: FAX# Date Service Completed (if already completed): J V ( ) Fee Amount: CITY STATE v1 ZIP C7 fI 3 'T BILLING ACKNOWLEDGEMENT: I, 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 my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAU S. �} APPLICANT'S SIGNATURE:DATE: U S g 751 $ROPERTY / BUSINESS OWNER❑ OPEfbkT9R-1' AGER E,� OTHER AUTHORIZED AGENT ❑ IfAPPL/CANT 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/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an,the same time it is provided to me or my representative. AyJwj:a '— TYPE OF SERVICE REQUESTED: I N V Roo L L CES COMMENTS: m t r� . _'� .�/I1 ' ^ � ��/� 1 ViVIV SOS o TO q y 18 2022 SMdOAQUtp yMq �ZCO UN �Try ACCEPTED BY: EMPLOYEE#: DATE: 10 ZZ n ASSIGNED TO: Q EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 0s2 P / E: Fee Amount: Amount Pai� �� Payment Date ,j /V�.._ Payment Type a Invoice # Check # 8 �l Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003