Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 1 FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> bo 7 11 <br /> SITE ADDRE S C��tlon /Jq/ (7I' Street Number �f StreAf Name C Ci jl Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) v <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> �1 ) <br /> PHONE#2 q Ll q � EXT, BOSDISTRICTLOCATION CODE <br /> (q��') 7 —1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I' /f� . ) <br /> 1 ` G ( V CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# �i_ - ,_ � EXT. <br /> HOME Or MAILING ADDRESS , s �i J (Ax#�/) <br /> CITY <br /> f/� V STAT GL� ZIP <br /> � <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,Standar s TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: � " ' DATE: 3'-4- <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, 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. <br /> TYPE OF SERVICE REQUESTED: SE ±-_2 RECEIVED <br /> COMMENTS: <br /> MAR 0 5 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL. <br /> HEALTH DEPARMW <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already c pleted): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment ate <br /> Payment Type , Invoice# 7Check#5`�� Receiv d By: <br /> Aft <br /> EHD 48-02-025 SR FORM(Golden Rod) t <br /> REVISED 11/17/2003 f`1 <br /> L�G <br />