Laserfiche WebLink
STAN JOAQUIOi7NTY EN"VI-RON-TTMENTAL HEALTH—F PA—RTNIENT <br /> SERVICE REQUEST <br /> Type of Business or-Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLWGADDIiEssb <br /> FAcum NAME `' �( . <br /> S(TEADoREss \\\1W 'C `A 'h2tt �tv�0.1'\-: �f+�^-t- �� L <br /> Street Number Direction - <br /> Street Name <br /> city Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number teet Name <br /> STATE _ ^ LP Cts 3L\ <br /> CITYC Fj <br /> SAo C- ,. <br /> PN�ONpEG#') I' APN# LAND USEAPPUCATION# <br /> (`^- `) • `� - ���� LOCATKJN CODE <br /> PHONEY - Ea. BOS DISTRICT <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REflUESTOR \ CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME <br /> v\l FAx# <br /> HONE or IIIAIUNG ADDRESS - 1 ) -( -• \\`T3 <br /> 00 Cm <br /> $TATE Cr0� LP <br /> ry We� �� <br /> I, the undersigned property or business owner, operator or authorized agent of same, <br /> BILLING ACKNOWLEDGEMENT: <br /> specific ENVIRONMENTAL HEALTH DEPAR'IMQ`TT hourly charges associated with this project <br /> acknowledge that all site and/or 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 JOAQUN <br /> COUNTY ordinance Codes,Standards;STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -1�/w.!/ V V"'a�r7 - DATE: <br /> �� rn CAh t \C3t�✓ <br /> PROPERTY/BDSP]r.SSOWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 9, T/tle <br /> IfAPPLJCANT'is not the B=JNGPAR Ty proof Of authoriiatlon to sign <br /> is required <br /> AUTHORIZATION TO RELEASE 1v-FORMATION:when applicable,L 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 envirorlmentaUsite assessment <br /> information to the SAN JOAQUnv 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 REOUES'TFD: - <br /> CONMENTS[ <br /> EMPLOYEE : . DATE: <br /> ..ACCEPTED BY: <br /> _. EMPLOYEE#: DATE: . <br /> _ ASSIGNED TO: <br /> PIE: <br /> Date Service Completed (if already completed): <br /> SERNLE CODE: _ - <br /> Payment Date <br /> Fee Amount. i AmounfPaid <br /> _.. Invoice. Check#.. Received By,. <br /> Payment Type _ <br /> - - SR FORM(Golden Rod)' - <br /> EHD 48-02-025 - <br /> ''REVISED 11117/2003 <br />