Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO� �� CHECK If BILLING ADDRESS <br /> FACILITY NAME J "� `- )y <br /> SITE ADDRESS'14. �,c � 1�Y.��v4=24 <br /> =2_I�b w'p I> �w <br /> Street Number Directio (�J et fie' `�`I f�`�t t <br /> HOME or MAILING ASS (If Different qm Site Addr s) <br /> 1 -- ` <br /> y Street Number Street Name <br /> CITY T P <br /> / <br /> .L <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 5> 765-tel Z� Cn 111- -oy <br /> PHONE#2 EXT. BOS DISTT LOCATION CODE <br /> ( ) n3 s <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br />;f CHECK If BILLING ADDRESS <br /> BUSINESS NAME / A✓ ) /,�l )`y PH NE# C�^ ` EXT. <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 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 d t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE E E L laws. / 2 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER �LLI <br /> / NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not theARTY proof ofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE I ORMATION: 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: Fi y <br /> COMMENTS: PO <br /> H�,y��R IN co 07,"'V <br /> JD' <br /> ACCEPTED BY: �� v�/1 Y 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed(if already comp) d): SERVICE CODE:�'n P/E: �2 <br /> W <br /> Fee Amount: C'L— Amount Paid Payment Date g, -2 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />