Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�� Ktv-" 01-) �-pr b o o SR�OsY`7 <br /> OWNER/OPERATOR <br /> G/ I cle r 'Sjo/ CHECK If BILLING ADDRESSO <br /> FACILITY NAME ��o <br /> SITE ADDRESS c� Y•-� "'_' <br /> —WC <br /> '"AGII, Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> V1 Imf �(I Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ` p �� /�— <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME { t'CPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 /> I also certify that I have prepared this application and Aat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard , STATE and FED AL la <br /> APPLICANT'S SIGNATURE: DATE: • ��'t� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 kt the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr /gym <br /> my representative. }� , (+ ■• <br /> TYPE OF SERVICE REQUESTED: C �S CUn cu 1t7A-h(in AfA <br /> COMMENTS: SAN ' <br /> ER Q'/N CO <br /> PCZU ZU CrJG1 yP-4 iyt,/-Ho PgRNrA�N <br /> cic- C, 7A60 <br /> ACCEPTED BY: ` f(t EMPLOYEE#: DATE: 5/)-9/1Cl <br /> ASSIGNED TO: l I Vl n EMPLOYEE#: DATE: 912-6/ci <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Jq[)2- <br /> Fee Amount: �s� U� Amount Pai /S:2v0 Payment Date 571-2,q <br /> Payment Type Invoice# Check# ��'�2-7 Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />