Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type ofBusiness or Property FACI�LI©iD#176 <br /> Sf , SERVICE REQUEST# <br /> OWNER/OPERATOR C/ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS / / / ` �nA ' ` {/yJ <br /> Street N er Direction Stye t me "Cf Zi Code <br /> HOME or MAILING ADDRESS (ijifferent from Site Address) <br /> Street Number Street Name <br /> CITY „ n STATE ZIP <br /> PHONE#1 (� ExT• APN# ^�,f 1 n P O ' ` LAND USE APPLICATION# <br /> PHONE#2 EM• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVIC REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAME[ <br /> HOME or MAILING ADDRESS F �� <br /> CITY ST ZIP(rI <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 a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT-8— <br /> IfAPPLICANT 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: RECEIVED <br /> COMMENTS: <br /> OCT 2 3 Zoos <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> n (7 HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I '�3 6� <br /> ASSIGNED TO: - - - --- — _ EMPLOYEE#: G?�I ATE: l <br /> Date Service Completed already comp) ted): SERVICE CODE: OO I PIE: 2 <br /> Fee Amount: Z O S Amount Paid 7f L S v Payment Date I i )3(p <br /> Payment Type �j Invoice# Check# 1,?-73 Received By: <br /> EHD 48-02-025 ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1�c <br />