Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ D <br /> OWNER/OPERATORA�'�� f C.�� <br /> ' ` _ .��.fV _ ,LU/Y CHECK if BILLINGADDRESSE] <br /> FACILITY NAME C <br /> JL ` VG D CL <br /> SITE ADDRESS I <br /> � 9itreet <br /> Number Direction Street Name ci Zip Code <br /> HOME Or MAII inlrr,A------ ' <br /> Street Number ' Street Name <br /> CITY -\;^ySTATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t C"-') <br /> C)(-Cy) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME SIjti) PHON # Ext. <br /> L� / L <br /> Aon <br /> HOME or MAILING ADDRESS n FAX# <br /> CITY �-i(iC �. 1 STATE i ZIP ( J 11 02 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 2a-5:� - `i DATE: <br /> � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT�G.1 <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 same time it is provided t0 me Or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 10 <br /> 41 <br /> 1 VF® <br /> a (J �W���S hl y �oR N�NC, 9 <br /> ACCEPTED BY: (31 r. EMPLOYEE#: DATE: f(' 2 / T <br /> ASSIGNED TO: EMPLOYEE#: ^' / DATE: ((�� ;,/ <br /> Date Service Completed (if already completed): SERVICE CODE: / !J I P E: <br /> Fee Amount Ab I 'QU Amount Pa �� O 7� Paymelll..n///t`D-l�ate Z/ <br /> Payment Type ; Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> y' V <br />