Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �� S900m ) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �E.49 ,,,J <br /> FACILITY NAME // <br /> C O ��l © � ��E` C r <br /> SITE ADDRESS S/� <br /> ,3 <br /> `! Street Number Direction rv` Street Name A city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 1 , / �II :� <br /> i2A �-i0� t�/Ji .. L'L ouee��+.....wr Street Name <br /> CITY STATE Zip <br /> G /+ 1�S- • S- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE 42 EXT. BOS DISTRICT LOCATION CODE <br /> (�G (9 L !o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME // J PHONE# EXT. <br /> LUf! D >� ��C � � �G� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY (/C STATE$TATE ZIP C,c C <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, STATE and FEDERAL laws. p q <br /> APPLICANT'S SIGNATURE: (� DATE: U 2 -1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof ofauthorization 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 /> to the SAN JOAQUIN COUNTY 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 SERVICE REQUESTED: C� u�� c NT <br /> COMMENTS: V RE ED <br /> AUG 0 2 2019 <br /> SAN JOAQUIN C OUNTY <br /> ENMRONME14TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: K .4- <br /> ASSIGNED <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: , Amount Paid Payment Date <br /> Payment Typ Invoice# 9bectt# q SSSS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />