Laserfiche WebLink
%VW .t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> ♦ FACILITY NAME (t I,)Q <br /> SITE ADDRESS �nu <br /> IttL c , • <br /> Streal Number Direction 1 , •Sttreel Name Cil Zi Cotlle/N\ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number. Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> IWI) tY 0 3 oZ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST R. M CHECK If BILLING ADDRESS <br /> ExT. <br /> BUSINESS NAME 11 PH NE# <br /> 6 <br /> oe <br /> HOME or MAILING ADDRESS FAX# <br /> CITY tMfi= CA <br /> STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 chargesassociated with this project <br /> of activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: .Nm 1%� k' DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHERAurnoRrzED AGENT I( Q,�nt(1111(Q, <br /> IfAPPLLCANT 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: WWCU 69 RELAI Jn1)1F_ 17CO—JACICt &A - <br /> COMMENTS: p. SAry_ oSSP 0 G <br /> 20 <br /> yEAtTNOq .oAT ' <br /> ACCEPTED BY: EMPLOYEE#: DATE: Lll , <br /> ASSIGNED TO: Z Q.f EMPLOYEE#: DATE: L <br /> Date Service Completed (if already completed): TT SERVICE CODE: 1 g P 1 E: .� <br /> Fee Amount: c� p Amount Pa' 3 6Ua 15D I Payment Date WLf <br /> Payment Type Invoice# Check# /S"r Rece ved By: <br /> EHD 49-02-025 SR FORM(Golden R <br /> REVISED 1111712003 <br /> �Q C . <br />