Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> / Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> — S V-/;k �' f C-OUn L -7 a 00�&3(.D�� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �� <br /> FACILITY NAME ILYr <br /> SITE ADDRESS ( G V G ( 1 e o `/ C ,A Wt-1treet Number Direction LStre it N e �'`ci Zip Code <br /> HOME or MAILING ADDRESS (If 'Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY Fv STAT ZIP <br /> II PHONE#1 Y 1ExVT• APN# LAND USE APPLICATION# d <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# 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 an at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an EDER <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA R OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Time <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 /> t0 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. <br /> TYPE OF SERVICE REQUESTED: � <br /> � G1 ��L / <br /> ` r 11 <br /> I V <br /> COMMENTS: <br /> y ,hRo <br /> �Ty�FAgRN�4N <br /> ACCEPTED BY: ' r fie n EMPLOYEE#: DATE: T <br /> ASSIGNED TO: �`�� `� G� V EMPLOYEE#: DATE: <br /> Date Service Completed (if already C mpleted): SERVICE CODE: I'� ( P I E: O'� <br /> v <br /> Fee Amount: ! .�� Amount Paid �S �� Payment Date u <br /> Payment Type Invoice# Check# ;_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ?fid 5z! <br /> s <br />