Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �3 <br /> OWNERI ERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS umber a r / r /(C �) h <br /> Street Number Direct rN I, — L e ame / Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Ad a s) <br /> Street Number Street Name <br /> CITU �, p STATE ZIP <br /> Y tW' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 3 -aC <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Py{lNe / EXT. <br /> E19 �4 <br /> HOME Or MAILING ADDRESS _ FAX# <br /> ��ll ,3 1) Y'oZ— <br /> CITY STATE / ZIP <br /> BILLING ACKNON GEMENT: 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 ' application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rd ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNA'T'URE: DATE: �Vla/Q�` <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 VV <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: PAYMENT <br /> COMMENTS: <br /> MAY 1 5 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: tiXels EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( , Q, PIE: rt <br /> Fee Amount: Z fJ' Amount Paid all :l, Payment Date 5 \S U'b <br /> Payment Type �� Invoice# Check# 1 b O 0 Received By: t� G <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />