Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property .FACILITY I���� SERVICE RE iJEST� <br /> u+ X11 v i (J[.�fJ v 1�'t'ihv� �,91 <br /> OWNER 1 PERATOR <br /> 'am Koo V .CHECK if BILLING ADDRESS <br /> FACILITY AME <br /> 04U LL <br /> SITE ADDRESS �Q.l s <br /> 1 Street Number "r!ectlon l Street Name t W ZI Code 1P <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20q) 5 G - L/9 8 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> i REQUESTOR - © CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> IN 5 7 a <br /> HOME or MAILING ADDRESS FAx# <br /> 1' ( <br /> CITY myl STATE C4 <br /> ZIP /_ /_ <br /> BILLING AG NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent loaf 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 busines /FERAL <br /> his form. <br /> 1 also certify that I have prepared is plicthe work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes, Stan rds, ws. <br /> APPLICANT'S SIGNATURE: DATE; _J I <br /> PROPERTY/BUSINESS OWNER OPERATOR I MAN ER [3OTHER 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 Iota at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess ' ion <br /> to the SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is ( <br /> my representative. Ven <br /> TYPE OF SERVICE REQUESTED: b [ U� <br /> AMR <br /> COMMENTS: $ <br /> AIV JQAQ[11N C <br /> li ENVIRO,V OUN7Y <br /> EAL7'y DEPgR McHr <br /> ACCEPTED BY: EMPLOYEE#: DATE: -t <br /> ASSIGNED TO: f EMPLOYEE#: DATE: _✓ ,1 <br /> Date Service Completed (if already completed): SERVICE CODE: D� i P1 F: <br /> Fee Amount: Amount Paid �� Payment Date <br /> ��/' <br /> Payment Type �� Invoice# Check# f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 071 7108 <br />