Laserfiche WebLink
SAN JOAQUI NK` UNTY ENVIRONMENTAL HEALTH L....tARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A-obbo a67 150 <br /> OWN1 OPERATO CHECK If BILLIN 7, �I CIO ADDRE 5❑ <br /> FACILITY NAME <br /> SITE ADDRESS /rs33 <br /> Street Number Dir6 .. t Name City Zip Code <br /> HOME or MAILING ADDRYli Different from Site Address} StreetNumt�er Street Name <br /> CITY t, STATE ZIP <br /> U <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> +aq ) � <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REGSTOR <br /> CHECK If BILLINGADDRESSED <br /> Y <br /> BUSINESS IMAM PHONE# ' <br /> HOME or MAILING ADD r FAx# <br /> IL r , ( ) <br /> CITY Q 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 <br /> or activity will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepared this application and that! work to be performed will be done in accordance with all SAN 3OAQLUN <br /> COUN'T'Y Ordinance Codes,Standar , STA FEDE <br /> APPLICANT'S SIGNATURE: DATE: �5rr 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER Er OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is n the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INl~ORMATION: When applicable, I, the owner or operator of the prop located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenmi nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and a�e�tIIeaeis <br /> provided to me or my representative. �1 <br /> TYPE OF SERVICE REQUESTED: FoLzl S 016 <br /> COMMENTS: NEgEN VIROM N QUN <br /> H DEPARTIWENT <br /> ACCEPTED BY: EMPLOYEE M DATE: 6, l <br /> ASSIGNED TO: EMPLOYEE M DATE: - j�'//0 I/0 <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: 0� <br /> Fee Amount: Amount P ' I-30 v Payment Date / <br /> Payment Type invoice# Check# 3 Z Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />