Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# Ev"IQL REQ ST# <br /> n c: <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME J <br /> SITE ADDRESS <br /> Street Number Direction Cl.` Street Name ` 1� HCl Ci Z,.413e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ' , r +lam <br /> 2-OZ -5- T Street Number 3t'reet Name <br /> CITY ^ � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S-,1(:: <br /> ^ Z'--t <br /> 7� CHECK If BILLING ADDRESS'�'� <br /> BUSINESS NAME yr Q PHONE# EXT. <br /> aC Ib S av k � r o -re acorn 'rl 5 4(9 <br /> HOME or MAILING ADDRESS FAX# <br /> ( 2&)) 109 - 1SZ5'- <br /> CITY S Q C j y`, STATE -pn" ZIP s- <br /> 7 Q <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 t '&application ae that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standa s,STATE an L WS. <br /> APPLICANT'S SIGNATURE: DATE: /?ifs <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER EU OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required !'isle <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: Pqy <br /> COMMENTS: ECEIVEL) <br /> APR 2 4 2019 <br /> HEENVIIRON N COUNTY <br /> MEN rAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /)�e I P 1 E:j <br /> Fee Amount: Amount Paid Payment Date 1 l i <br /> Payment Type Invoice# Check# Received By: , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />