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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f AAA-t; � ,i � -F -clo i 4�__�z ��; t�0 Z�S <br /> OWNER/OPERATOR <br /> Gg--i s1-o bq 1 M _ CTC? , ECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS Z�I 2 c� <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 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 /> 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE nd FEDERAL I ws. <br /> APPLICANT'S SIGNATUR / DATE: <br /> PROPERTY/BUSINESS OWNER OPERA OR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required 7'l rle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. PA I— <br /> TYPEE OF SERVICE REQUESTED: C v f� Cul)',U t6,��UTF R ` <br /> COMMENTS: 1 1 I Pik- CAD <br /> l,AWz UIN CO o19 <br /> �Ty�EpgRNr�Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � } EMPLOYEE#: DATE: 2 <br /> Date Service Completed (if already completed): A–I'2SERVICE CODE: IE: ICIU <br /> Fee Amount: Amount Pa* � Payment Date <br /> Payment Type (3�t6Invoice# Check# Rect;ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />