Laserfiche WebLink
k <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> , T <br /> SERVICE REQUEST <br /> Yype of Business or Property FACILITY ID#" SERVICE REQUEST# l <br /> OWNERIOPE O l CHECK if BILLINGADDRESS <br /> FACILITY NAME' <br /> SITE ADDRESS �12'ty'f/ �11�, J jiGLG l g�J 7SU <br /> Street Number Direction Street Name I Zip Code <br /> HOME or MAILING ADDRES (If Differe t from Site Address) <br /> SYy Street Number Street Nam <br /> CITY STATE ZIP <br /> BS <br /> PHONE#1 ExT• APN# LAND YSE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR l <br /> REQUESTOR r ! <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE#� <br /> HOME or MAILING ADDRES FAX# <br /> /.7 { ) <br /> CITY STATE ZIP <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor project specific ENVIRONMENTAL HEALTH DEPARTMENT-1-- ',y 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 Mone in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standardsa�a <br /> � v <br /> ' ._APPLICANT'S SIGNATURE: <br /> PROPERTY I BUSINESS OWNER❑ C' n of I <br /> If APPLICANT is not the B, l ( / � � Title <br /> AUTHORIZATIONTO RELEASE INFOI �tF f the property located at the above <br /> site address, hereby authorize the releat :.. mental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTt_ s same time it is provided tWne Or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: T l C • <br /> COMMENTS: <br /> hI�FNOq VIN 16 <br /> LirHDF Aq ,Og�N�Y <br /> i <br /> ACCEPTED BY: _�_. LOYEE M DATE: <br /> ASSIGNED TO: 1 ` }(y) F EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: � PIE: <br /> Fee Amount: Amount PAZ3�0 (� Payment Date -71ps` <br /> Payment Type Invoice# Check# Rec ived By: <br /> I EHd 48-02-025 SR FORM(Golden Rod) <br /> iii 07/17/08 <br /> 1 <br />