Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE RIQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Io C"� SRW81mG2 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME J _ <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING <br /> ,ADDR S (If Different from Site Address) <br /> r "'✓- ej"' Street Number Street Name <br /> CITY STATE -, zip <br /> _5..2a <br /> PHONE#'I Exr. APM4 LAND USE APPLICATION# <br /> PNO E#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> FT W L, CHECK if BILLING ADDRESS <br /> BUSINESS NAME f 1 PHONE 4 EXT. <br /> } <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 forth. <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 FEP7RAL <br /> APPLICANT'S SIGNATUR <br /> W-1 DATE: -Z3- 23 <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, geotcehnical 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 jute it is <br /> provided to me or my representative, jW& r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3 <br /> ��Ro N co�23 <br /> FatTyp pM CE,y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO' EMPLOYEE#: DATE: 12-3 <br /> Date Service&rnpleteci (if already comp) ted): SERVICE CODE: P �3 <br /> Fee Amount: 21 Amount Paid 16-Z 01-31 Payment Date ��S 2 <br /> Payment Type Invoice# Check#� 76` 'T' SCE Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />