Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />OVD17Tf'R DVnITPQT <br />CONTRACTOR! SERVICE REQ UEbrvx <br />FREQUESTOR c�j'�; ,,pOH A 1.L , to c! fi /l CHECK if BIWNG ADDRESS LJ <br />IL_.�, <br />BUSINESS NAME —{-It �el. i vet �s-�'r� <br />PNONE# <br />ijail <br />HOME or MAILING ADDRESS <br />(M# <br />( ) <br />Cm STATE <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator ozed agent of samev,.. <br />HEALTH DEPARTMENT hourly chargted with this project. <br />acknowledge that all site and/or project specific ENVIRONMENTAL <br />or activity will be billed to me or my business as identified on this form. <br />ithe <br />1 also certify that 1 have prepared this application and that the work to be performed will be done in accith all SAN fOAQLTN <br />COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br />�b 2D23 <br />APPLICANT'S SIGNATURE: ,/1 yr I�WW 1�A DATE: <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 _ <br />IjAPPuafA7 is not the BILLING PARTY, proof of authorization to sign is requiredTitle <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operatoroperty located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br />information to the SAN ]OAQUIN C0UNTY 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: <br />COMMENTS: I `� G`V'V/Il ( V1-Q1LIh". L <br />/_ <br />ACCEPTED BY: L`J-I I )" <br />EMPLOYEE #: <br />DATE: •3 I l '� <br />ASSIGNED TO: ���,-�� �— EMPLOYEEM ?' 913 DATE• 3 I 23 <br />Date Service Complete (if already completed): SERVICE CODE: 061 P I E: 16 D 2 <br />Fee Amount: d' <br />Amount Paid 'V <br />Payment Date ^_ I R <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 4"2-025 <br />REVISED 11/172003 <br />coot'# s 71 53 S - II <br />SRy RM (Golden Rod) <br />