Laserfiche WebLink
SAN JOAQN.,4 COUNTY ENVIRONMENTAL HEALTrrDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C© A/ (/O/VIOC-) S LL �ROZD ��-79-?Q0 <br /> OWNER I OPERATOR /,/L) /9 Al CHECK If BILLING ADDRESS <br /> FACUTYNAME <br /> SRE%DggESS� <br /> '7 7 �l , e, • C it Coae <br /> Street Numb Olrectionstmet Name <br /> HOMEorMAID ADDRESS I�fferent from Site Addres <br /> (a i Ad <br /> Street Number Street Name <br /> CITY 0 A-/ f ESTATE —zip (p <br /> p /' <br /> PHONE#1 ,` Enc APN# I _ ��(LAND USE APPLICATION# S <br /> (2-0 5 ) �/� /�S"Z <br /> PHON Ev BOS DISTRICT / LOCATION CODE <br /> (zo r, 39--797 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK if BILLING ADDRESS O <br /> BUSINESS NAME <br /> PHONE# Ear. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 ENIvatONMENTAL 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 FEDURAL <br /> laws. <br /> �,�/� <br /> APPLICANT'S SIGNATURE: J? �//"9/// DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> 1fAPPLICANT is not the BLLLtNG 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 /> CC:IV <br /> TYPEOF SERVICE REQUESTED: ?EFC r .' <br /> COMMENTS: SEP 0 6 <br /> SAN JOAQL/n C.0 <br /> HEALTry p�pRTI l_ <br /> ACCEPTED BY: EMPLOYEE#: - - DATE: ' <br /> ASSIGNED TO: EMPLOYEE#: - DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invdice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />