Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> C SERVICE REQUEST <br /> l Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> r�O r CHECK If BILLING ADDRESS <br /> kA <br /> FACILITY NAME <br /> SITE ADDRESS <br /> D <br /> Street Number Direction I \ Street Name Ci Zip Code <br /> HOME or MAILiN ADDR SS (If Diff rent from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Y 2 r C4 C- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> V-"7) 3 --3k6Z <br /> PUQD }IZ CL49 I' T5 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r O�p E V� CHECK If BILLING ADDRESS I <br /> (21 <br /> BUSINESS NAMES ` PHONE# EXT. <br /> a <br /> HOME or MAILING AD ESS'I # (�w <br /> I Lk 21 376 <br /> CI 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 /> 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,ST E and FEDERAL laws. <br /> A # <br /> APPLICANT'S SIGNATURE: C) DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING 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 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 sarljg t�1'�1Q,�t�ly�Q�ed to me or <br /> my representative. <br /> F7AYMtl�A <br /> TYPE OF SERVICE REQUESTED: t��✓� Gf9P10� <br /> COMMENTS: MAY <br /> 0'4 ZU16 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: MG(Ni EMPLOYEE#: DATE: l(P <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 413D•CA:> Amount Paid C7 Payment Date <br /> Payment Type I Invoice# Check# Received By: -� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />