WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Tyf Business or Propert pe C' -i> k) I � 4�� %A FACILITY ID # SERVICE REQUEST # ) (- � 9 OWNER / P ATOR - V CHECK if BILLING ADDRESS FACILITY N Lk SITE ADDRESS CITY �• — ATE Z,P C, EMPLOYEE #: I/ I C c- Date Service Completed (if already completed): Lyl-�r'TD" PIE: treet Number Direction Payment Date t ame Payment Type Invoice # Check # I / HOM r DRESS (If Differe om`Site ddress) -'A u 1 S -- reetRlumber ree Naml CITY STATE( ZIP PHONE #1 ExT• c-- Al N# LAND USE APPLICATION # PHONE i{2 EXT. BOS DISTRICT LOCATION CODE � ( ) Com' ! CONTRACTOR / SERVICE REQUESTOR REQUEST R I CHECK If BILLING ADORES BUSINESS NAME `` PHON # EXT. .. • � HOME Or MAILING ADDRESS ^ ` � � ` ^ # EMPLOYEE #: (AX CITY �• — ATE Z,P C, 1 BILLING A KNOWL &GEMENT: I, the undersigned property or business owner, o erator or authorized agent of Same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE nd FE ERAL laws' APPLICANT'S SIGNATURE: =— DATE: S Z.2 2 - PROPERTY PROPERTY I BUSINESS OWNER ® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses�t t information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the same time It I�pI]le Or my representative. �I R��(�C�. 1yl t TYPE OF SERVICE REQUESTED: 1' CST I f 1 Vu C -..,VRMA �.O COMMENTS: ,1 e` q v , ZO �vJoq 18 F QUI �EPgRNT /v MFNt ACCEPTED BY: t EMPLOYEE #: DATE: kk I �� ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: �� PIE: Fee Amount: C7- Amount Paid S h� Payment Date Payment Type Invoice # Check # I / Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08