Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 FP C 6 L2 c�&tj-:� t) <br /> OWNER/OPERATOR n�A P <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS L C ' � V ( C/ijI <br /> 1_ l;l v Q _t rG /' c) <br /> � t N�mhe Direction Street Name f Zip Code <br /> HOME Or MAILING ADDRESS If Different Site Address) r. /� ,�p��t� <br /> �i �r GY �r Street Number '` �r S eet Oame <br /> CITY STATE n ZIP 2��U� <br /> O 1/7 - C(j '11h, <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> z ( 2 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) � 11 -T)�— <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ ` CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 , (� I PHONE# ExT. <br /> v YC ' fb <br /> HOME or MAILING ADDRESS FAX# 6-ft-,)5_72--k91-7 <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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JQAQUiv <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. /2 1 <br /> APPLICANT'S SIGNATURE: —��� DATE: 7 <br /> PROPERTY/BUSINESS OWNER M 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, 1, 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. - PAYM NT <br /> TYPE OF SERVICE REQUESTED: 60 RP. <br /> COMMENTS: D <br /> PUe- t:vC��vr -crr�s' � ��2L' o i 15 <br /> +liN <br /> SAN JdGSCO NTY <br /> V T UNTY <br /> H <br /> HEALTH DEPA MENT <br /> ACCEPTED BY: l�'�.n �� EMPLOYEE#: DATE: '7/3 <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q� P/E: 6 � <br /> Fee Amount: C) "D 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 />