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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tk'eCof Business orAropert � ��Fy,Cl�l�Y,ID# SERVICE REQUEST# <br /> Gll(rl d <br /> OWNER I OPERATOR YCI Wr G4 � /tNU,CC" CHECK if BILLING ADDRESS <br /> I � '1 �1/� G � <br /> FACILITY NAME ) ��v Ct &�"Q-cv <br /> SITE ADDRESS ( ` �� l/J�C� <br /> Street Number Direction UJ PJ f V Street Name I J l v� i " + 1 Zip Code <br /> HOME Or MAILING A RESS (If Different from Site Address) (/ ��//��/� <br /> Street Number V I1 S{reef Name <br /> CITY S4T Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE#S� EXT,3�id —��3 <br /> HOME or MAILING ADD ESS FAX# <br /> C ( ) <br /> CITY f STATEUPI <br /> ZIP J-2 f <br /> J ri / <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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER-P OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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. A <br /> TYPE OF SERVICE REQUESTED: (A � F <br /> COMMENTS: ✓/� VA� <br /> 0 <br /> 19 <br /> N�ITy�F MFCO�Nry <br /> ACCEPTED BY: r <br /> Lo EMPLOYEE#: -"o <br /> 9 DATE: /,� / <br /> ASSIGNED TO: n EMPLOYEE#: VV DATE: ! r I <br /> Date Service Completed (if already completed): SERVICE CODE: ow/ PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type \"� Invoice# Check# Received By: , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ,S <br />