Laserfiche WebLink
SAN ,IOAQUIN COUNTY ENNARONN1ENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME C- � <br /> SITE ADDRESS i f2l <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ' 1J K� Ll Street Number Street Name <br /> CITY STATE ZIP �U(S <br /> 1OAu CCP .�rt� q <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ((<_'S u) t.9 q,0-57®- o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR T <br /> `� A CHECK if BILLING ADDRESS <br /> BUSINESS NAME L I 1 PHONE# EXT. <br /> HOME or MAILING ADDRESS j, FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 /> COUNIY Ordinance Codes,.Slanchirdr, STATE and�FED/ERAL laws. <br /> APPLICANT'S SIGNATURE: _�i�' J �' DATE: <br /> PROPERTY/1311SINESS ONVNER.CJ OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT❑ <br /> i1'.41'PLICANT is 1101 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 at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Q 0 7d LAS f G iL4 f--- L <br /> COMMENTS: <br /> ACCEPTED BY: U t ,Z /t EMPLOYEE#: O Z DATE: <br /> ASSIGNED TO: l �J /1 A1�-7_ EMPLOYEE#: �2/3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE. S P 1 E: (O� <br /> Fee Amount: J/`o L7 Amount Paid 3�� s Payment Date $ f `L• 1 0 q <br /> Payment Type ✓_ Invoice# Check# s Received By: N-r, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />