Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-)9S J—I R 7i 6 YJ3-13�- '�C�b7 of s <br /> OWNER/OPERATOR <br /> 16)9!�J Y? Sic <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME � q /J��J / �/J�' <br /> SITE ADDRESS 770 0 <br /> Mo <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 0 Street Number Street Name <br /> CITY (7 �� J/_rG1i1 STATE ZIP 9 <br /> PHONE##1 T EXT- APN# /, LLA/ND/USE APPLICATION# <br /> (aC(i) q 7. s3 q � 1�e v <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .�-�' r <br /> `J CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESSn FAX# <br /> 7 7 CC) roD 1"opa't4 <br /> CITY ^�!�yt _7 1 2 STATE ZIP J— / <br /> BILLING ACKNOWLEDGEMENT: 1, 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,WTE and FEDERAL laws. ) <br /> APPLICANT'S SIGNATURE: DATE: / I� <br /> PROPERTY I BUSINESS OWNER❑ ERATOR A�ER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PAR . uthorization 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 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 t0 me Or <br /> my representative. _ <br /> TYPE OF SERVICE REQUESTED: <br /> U 5) t�17 tom. rz-e� <br /> COMMENTS: 11III <br /> JAN JOA.Q il, COUNTY <br /> ENVIROnRENTAL <br /> HEALTH DEPARTNIENT/ <br /> ACCEPTED BY: '-'ea rr� EMPLOYEE#: DATE: 7 - � <br /> ASSIGNED TO: �jr EMPLOYEE#: DATE: U< �(C <br /> Daie Service Compieted (if already completed): SERVICE CODE: 4� a P I E: JC <br /> Fee Amount: — Amount Paid 3 C7 Payment Date cS I 1 (� b <br /> Payment Type �� Invoice# Check# Received By:1 <br /> r�/GU I <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />