Laserfiche WebLink
C 0 <br /> SAN ,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> i ` <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 ? —s ��fOCPq/ / P <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS� <br /> FACILITY NAM S <br /> FSIT�E)ADDRESS lS?_. P v e �-4ck .� Y� <br /> C <br /> ! l � DL�9Streel Number pirectian Street Name Ci Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) C/i t-r-O�cam, �5 <br /> t Street Number f Street Name <br /> CITY STATE ZIP <br /> 'k 015-3U1 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 4 <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME 11 PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> { ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> s acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and PED- L laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 <br /> PROPERTY/BUSINESS OWNEK�KI OPERATOR/NIANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTT is not the BILLING PARTY proof of authorization to sign 1s 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: 4`ftlT <br /> UU <br />' COMMENTS: 4 v <br /> 5 2012 <br /> 6AN 3 c <br /> a ACCEPTED BY: EMPLOYEE#: DATE: f �} <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: P 1 E: <br /> Fee Amount: Z S Amount Paid Payment Date <br /> Payment Type � Invoice# Check# D3 0 Received By: <br /> i <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />