Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Go MMS l�ct n L g ter--) <br /> OWNER/OPERATOR A i . + , �rcA n <br /> NI/vat,�.,lY1'n f./� v�fV CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Z� 'J 1 r= �v�L�/ rcf <br /> Street Number Direction I Street Name Cit l' ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2-5-713 <br /> I/1 (F✓ <br /> Z— (�l.<�J Street Number "U v Street Name <br /> CITYt A '� �TE ZIP <br /> PHONE#1 �/�/ ExT• APN# LAND USE APPLICATION# <br /> 37 6 05 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A ��� f4 ou I� ' L 5 CHECK If BILLING ADDRESS <br /> BUSINESS NAME � /f 1'— <br /> J� �� U P�I�E# � , EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �' TATE ZIP 'q <br /> BILLING ACKNOW EDGEMENT: 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 o his r <br /> also certify that I have prepared this application and at he w rk t e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDE LI v �I <br /> APPLICANT'S SIGNATURE: DATE: 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN OTHER AUTHORIZED AGENT ©' <br /> If APPLICANT is not the BILLING PARTY,proo 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses ent Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time Itls' d to me or <br /> my representative. �•rr <br /> TYPE OF SERVICE REQUESTED: G'G P <br /> COMMENTS: S.Q.✓O ?�s <br /> FN <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: i <br /> Fee Amount: J ' Amount Pai Lis/ O Payment Date <br /> Payment Type Invoice# / Check# —Yl/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> Z37 �aSp.n �e gtrt. <br />