Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of B mess or Property FACILITY ID# SERVICE REQUEST# <br /> � 51 � t <br /> OWNER/ PERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME f <br /> SITE ADDRESS <br /> Dir ��,✓� .5` <br /> Street Number ection Street Name Zip Code <br /> HOME or MAII-m ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> � l <br /> CONTRACTOR / SERVICE REQQUESTOR <br /> REQUESTOR / <br /> L✓ CHECK If BILLING ADDRES <br /> BUSINESS NAME PH EXT. <br /> HOME or MAILIN DDRESS _ FAX# <br /> 2 <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 l 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, STATt and FEDERAL laws. <br /> r <br /> APPLICANT'S SIGNATURE: I DATA',:re �<- <br /> PROPERTY/BUSINESS OWNER F-1OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT/�p.L\(� <br /> IfAPPLiCANT is not the BILLING PARTY:proof of authorization to sig9'n 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: VS T graQa i <br /> COMMENTS: Q f <br /> '0 <br /> ACCEPTED BY: EMPLOYEE#: bATE:- <br /> ,ASSIGNED TO: EMPLOYEE#: I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE- <br /> Fee <br /> !E:Fee Amount: W Amount Paid enybate ir., <br /> Payment Type Invoice# C eck# Received By: <br /> EHD 48-02-025 SR 0bRM(�oiden`R6d) <br /> REVISED 11/17/2003 <br />