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t�>�n C) i <br /> l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I IT)e-d, � TS?40(2)8-�5:S�3 <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE DDRESS <br /> Stroot Numbor Olroctlon �r Stdreeit Name ill Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) - <br /> Street Number. Strout Namo <br /> CITY STATE zip <br /> PH0NE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> L ) <br /> CONTRACTOR/ SERVICE RE' QUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS U - <br /> BU S NA <br /> EXT.SHomEorMAIL ADD ES P. i, FAX CITY C /,l STATE q 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 specihc 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,Standard TE a FED RAL a <br /> APPLICANT'S SIGNATURE: --�" DATC: .:? �a <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENTK IB'LCI(:-`�1(,,z-., <br /> IfAPPLICANT is not the BILLING PAR TY proof of authorization to sign is required Titre �. <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 Is'NVIRONMENTAL HSALTI-I 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: i ( t f <br /> COMMENTS: p <br /> sqN DEC� � ?02,� . <br /> �0q <br /> NF-LTN o p 1EJv �Nry <br /> ACCEPTED BY: EMPLOYEE#: C DATE: 1.2 <br /> t, <br /> ASSIGNED TO: EMPLOYEE#: DATE: / <br /> � I<. r <br /> Date Service Completed (if already completed): SERVICE CODE: p 1 E: .f r <br /> Fee Amount: ;r, Amount Paid Payment Date i <br /> 14 <br /> Payment Type � � Invoice# Check# f?� Z3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />