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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE[REQ ES# <br /> OWNER/OPERATOR t� <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS V C)U <br /> Street umber Direction Street Name Cit Zi Code <br /> /� A <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 'L S I (:'� �— f ^-'� ) �-E ��' Street Number <br /> Street Name <br /> CITY n lJ �l �ST�ATE �Z�P <br /> 1() 11 <br /> PHONE#1 LJ EXT, APN# LAND USE APPLICATION#, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <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 or <br /> 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. / C <br /> APPLICANT'S SIGNATURE: DATE: <br /> _r <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same tlmt j�,plovided to me or <br /> my representative. �`1 T <br /> TYPE OF SERVICE REQUESTED: La f-S (cm S vA <br /> COMMENTS: JUN <br /> Cps;RS 0� A 94'06 I-G SAIV jo9 2019 <br /> FACTyDepM ��NOUNTY <br /> ACCEPTED BY: L(`1 r-,ri EMPLOYEE#: DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: tt� C1 <br /> Date Service Completed (if already completed): SERVICE CODE: G jp PIE: 1461Z <br /> Fee Amoun ls� D D Amount Pa' 3W 6 Payment Date I <br /> Payment Type Invoice# Check# q,2� 732 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />