SR0082750 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# V 169 E��I IL 50--) wzz (p OWNER I OPERATOR CHECK If BILLING ADDRESS FACILITY NAME jSITE ADDRESS `` � �t►t \ l t-�(K o„t L4\- ': l S1 'F 1�, - C- Street Number Direction Street Name Cit ZI Code HOME or MAILING ADDRESS (If Different from Site Address) ('' /` C y Street Number �I treat Name CITY tTATE ZIP L.6)bm <Al T;16-'C70 PHONE#1 EXT. APN# LAND USE APPLICATION# (41.,r) -9�5( 6553 -(D80-2-0 p �o o0 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR ^ ^ CHECK if BILLING ADDRESS❑ BUSINESS(NAME PHONE# EXT. HOME or MAILING ADDRESS � FAX# q�;ZSV STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authoriatf A nt�same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges assr ed wit 1 ftect or activity will be billed to me or my business as identified on this form. N�E,NVIRpNtN CO�Nn, I also certify that I have prepared this application and that the work to be performed will be done in accordance�RRW�&QUIN COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. FNT APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNERLLJ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 1 TYPE OF SERVICE REQUESTED: V�Y( n }jo n bC tesireon" c 7)C, COMMENTS: cGI -707 t. InSpe"f 6", �l� �►oor adV60(f no'ke Telt4,lie ACCEPTED BY: Z" EMPLOYEE#: DATE: ASSIGNED TO: A EMPLOYEE#: DATE: Date Service Completed (if already Completed): SERVICECODE: VC P i E. Lia Da Fee Amount: a Amount Paid Payment Date Payment Type Invoice# Check# Received By: a j EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003