Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR i <br /> t CHECK If BILLING ADDRESS <br /> G <br /> FACILITY NAME / <br /> SITE ADDRESS /02 u / <br /> / Street Number Direction 5 r N me t/V cityC-ZI%Co <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> '~ � Street Numlrer Street Name <br /> CITY I STATE ZIP <br /> PHONE E r. APN# LAND USE APPLICATION# <br /> 3_/zk . <br /> r <br /> PHONE# _ ET. BOS DISTRICT LOCAnO ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME -7 PHONE Exr. <br /> 0 !/ <br /> HOME or MAILING ADDRESS FAX# <br /> Z ( ) <br /> CITY STATE ZIP S j1 <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 appirtition and that the wor o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TE and FE law . <br /> APPLICANT'S SIGNAT DATE: —z::;) 1 —OA <br /> PROPERTY/BUSINESS OwNEwEf 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 at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite 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: <br /> t <br /> COMMENTS: GAle <br /> lozl�rw JUL 3 1 cu08 <br /> 6AN JOAQUIN COUNTY <br /> Ilpt.' iI/4J> HF.ALTHRDIS A TNE�NP <br /> ACCEPTED BY: - EMPLOYEE M DATE: <br /> ASSIGNED TO: O EMPLOYEE M O`er DATE: <br /> Date Service Completed (if already wmpleted): SERVICECODE: PIE: <br /> Fee Amount: l tr Amount Paid 1 LL- jr) Payment Date <br /> Payment Type Invoice# Check# U2,44 'ot Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />