Laserfiche WebLink
3AN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR+n n�M Y <br /> '�I 1 W CHECK If BILLING ADDRESS <br /> FACILITY NAME. . !]�� l / <br /> _ __-- - -- _Ito. <br /> SITE ADDRE <br /> / V.don <br /> / Street Number rte`^ StreAtMdme Ci,t Zip Code <br /> HOME or MAILING AQDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 7 ) <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR f , + / + ) CHECK If BILLING ADDRESS <br /> BUSINESS NAME e , / PHONE# , Exr. <br /> `J - lG � <br /> HOME or MAILING ADDRESS , J/� yry , FAX# <br /> J LL(�/V ( ) ial. <br /> CITY p STAT 14C. ZIP 1354- <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,Standar00 <br /> TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `r/I [ DATE: ~�7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> /7Ql <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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): $ER`JICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check 4 Received By: <br /> . ........ .... <br /> EHD 43-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />