Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property :> FACILITY ID# SERVICE REQUEST# <br /> dD�OS`7 Sgoo yoo <br /> OWNER/OPERATOR / , CHECK If BILLING ADDRESS E] <br /> FACILITY NAME •) <br /> / <br /> SITE ADDRESS <br /> 1�4Street Number I Direction Street Name i Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYGSTATE ZIP <br /> Si /�k'l;lrC� L�, l 9 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> W - V P- 5632 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR l/ <br /> CHECK If BILLING ADDRESS <br /> Cr- ii/jjj <br /> BUSINESS NAME I PHO E# L �— EXT. <br /> HOME or MAILING ADD SS ✓ FAX# <br /> , <br /> r c �o? GSA S ���lc��'t� c, �G ( ) a S�3 <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 applicationand that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E and FED AL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tir1e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it �l t a or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �(/,� / Z) ��'K O- <br /> ReeEIVED <br /> COMMENTS: JAN <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: / °`J ( � DATE: ( (f <br /> ASSIGNED TO: EMPLOYEE#: 17`+ DATE: <br /> Date Service Comp eted (if already completed): SERVICE CODE: P/ : 1 <br /> Fee Amount: 3O O U Amount Paid 3 b — Payment Date l <br /> it <br /> Payment Typet Invoice# eck# S S�p g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> P�,o I�Io2q � <br />