Laserfiche WebLink
• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RUSH <br /> SERVICE REQUEST <br /> Type of Business orPr perty FACILITY ID# SERVICE REQ ST# <br /> (4 1&— zon r 3 �coq-2-we) <br /> OWNER/ PERA OR <br /> CHECK If BILLING ADDRESS <br /> s r1�s c� _ >2,� c'o <br /> FACILITY NAME CIA Ae-0 <br /> SITE ADDRESS Streit I�hh le—C9, <br /> ^ <br /> 1 Z.ZU s".,Number Direction beet Nmne C `lCo7de <br /> HOME or MAILING ADDRESS (If Different from Site ddress) <br /> Street Number Stmat Name <br /> CITY STATE ZIP Gl <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT <br /> ^ LOCATI C DE <br /> ( 1 U <br /> / SERVICE REQUESTOR <br /> REQUESTOR <br /> T I0 r CnrteYV\0 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> 10 k—�Ax-u <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING (JLlAC:KNOWLEDGEMENT: 1, 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 and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codes,Slundurd STATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: �J 1 <br /> PROPERTY/BUSINESS OWNER❑ OP. NAGFR ❑ 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> �� <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> � <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: • V wa V/v '��� <br /> COMMENTS: <br /> cod ,8 <br /> �P '�FiyT <br /> ACCEPTED BY: ,.` EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed. SERVICE CODE: �3 P I E: r 6 U <br /> Fee Amount: . Amount Pa' Qd-� Payment Date <br /> Payment Type C �l Invoice# u C ck �rj� Rece ed By: <br /> EHD SED 11/1 ��� Li � �e- SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ( � �1!`� 0` <br />