Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR4�` <br /> CHECK If BILLING ADDRESS D <br /> FACILITY NAME <br /> SITE ADDRESS Ave } Gj�� <br /> v� Street Number Di Ion 5 teat Name <br /> HOME or MAILINo ADDRESS (If Different from Site Address) �►sv�/ ,� � <br /> 20 Street Number f Street Name <br /> CITY � 1��n STATE q,� ZIP <br /> PHONE#t ^i vY l Err. APN# i LAND USE APPLICATION# <br /> PHONE Exr. BOS DISTRICT LOCATION CODE <br /> c2t► )3?�'�'�(3 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR k�1, A t& CNECK if BILLING ADDRESS <br /> BUSINESS NAME (�� /I.�,..1(t J PH NE y n <br /> HOME Or MAILING ADDRESS � � � (Ax# ) I <br /> 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,Stan ards TATE and FEDERAL laws. � / r <br /> APPLICANT'S SIGNATURE: DATE: !r�/� 1 q <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPARTY 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. AA <br /> TYPE OF SERVICE REQUESTED: Lo nsu I v of i U r) R F <br /> COMMENTS: D a n o 1 1 1 1 O <br /> PGy (3�11i r1 �oRQU/�8 ?®19 <br /> A ni IAC d n It �s l ibis LryO�pq�H 144 <br /> ACCEPTED BY: EMPLOYEE M DATE: /S <br /> ASSIGNED TO: i'M C 0 e i 1 d n EMPLOYEE#: X41 13 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1. 061 P/E: t 91 03 <br /> Fee Amount: S '� ©� Amount Pai lso� Q� Payment Date 7 <br /> Payment Type L5..-- Invoice# Check# �cSbG Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />