Laserfiche WebLink
6 <br />JOAQUIN COUNIITY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />FACILITY ID # �E UI REQUEST�%R <br />Ffo� C)o Vb 59 <br />r i't *'�e-ffl C-1cf IV 0 1 CHECK if BILLING ADDRESS L_ <br />BUSINESS N{AL1^ <br />e tA <br />-t(-c,(\�� <br />Drection Street Name G Zin Code <br />`erent from Site Address) <br />A-V� Street Number <br />_Street Name <br />SI.� ZIP <br />r <br />C* /�� 3 1 , U STATE Zip <br />LAND USE APPLICATION ff <br />-� <br />cz-• <br />+ <br />BOS DISTRICT I <br />I{ <br />LOCATION CODE <br />CONTR&&TOR / SF.P%rT 'F RFOTTF.STOR <br />REQVZSTOy, . <br />J/ ,!j P/, <br />/ <br />kW <br />V 1t'� <br />L CHECK If 81LLING ADOP,ESS <br />(( (/l (! <br />BUSINESS N{AL1^ <br />e tA <br />n <br />(J <br />FND`fE j EXT <br />HOrr;E Or M MLING AD RESS <br />FAX" <br />CMM . <br />C* /�� 3 1 , U STATE Zip <br />BILLING ACKNOWLEDGEMENT I, the undersigned property or business owner, operator or authorized agent of same, <br />2cKr c -hedge that, all Site and/cr project speciric ENVIRONMENTAL H&zTH DEPARTMENT hourly charges associated With this project or <br />_:::wity will be billed to me or my business as identified on this form. <br />1 a's�, certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQU;N <br />Cc --,-,y Ordinance Codes, Standards, TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:, � 01 <br />DATE: '7 <br />BUSINESS OWNER OPERATCP. I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APP-11CANT iS not the BILLING P,.RTY, proof of authorization to sign is required Tir; <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator cr the property loca,ed at the above <br />site address, hereby authorize the release of any and all results, geotee4nical data and/or envirermental/site assessment information <br />to the S: -�j JDAOUIN COUI•iil' ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided to me or <br />My representative. <br />TYPE OF SER1,90E REQUESTED' CL 1 <br />CO?.i?.tEtri 5: <br />ACCEPTEO BY: <br />Et.1PLOYEE n: <br />A5SIGNED rC: <br />— — --_- -- � EISiPLOY'cE r; <br />D Ito Service Completed (if already completed): SERO;ICE C0CE: <br />I've Amount:' 2 _ I Amount Pai �5. ,�/� Payment Date <br />Payment Type �" - Invoice r hseC�•—�� <br />DATE: )iZ4LT�R <br />F <br />DATE: <br />P? E: <br />Recc;ved Et, <br />