Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ..OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> IIUr Street Number Street Name <br /> CITY STAT _ ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> rPHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 21iiA—e <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. 4, <br /> APPLICANT'S SIGNATUR16 Gt,am,n /�?L� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thee it is <br /> provided to me or my representative. �C <br /> Itir <br /> TYPE OF SERVICE REQUESTED: Mobile food facility cosultaion. 'E <br /> COMMENTS: 7 <br /> NVjgQw�4l CJ <br /> '11Fd� <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: )� 2 <br /> ASSIGNED TO: a/] 1 EMPLOYEE#: DATE: AF/1-7'/Z,3 <br /> Date Service Completed (if already Completed): SERVICE CODE: 06 1 P E 603 <br /> Fee Amount: 156 1 <br /> Amount Paid / Payment Date 411-7-/2 2> <br /> Payment Type Invoice# d D O `� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />