Laserfiche WebLink
SAN JOAQviN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERUIGE*E?EST# <br /> OWNER/OPERATOR <br /> 1 ` �) CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> O AN N V\'J"'Li <br /> (n <br /> SITE ADDRESS � � �9t. C �U <br /> CZ-01 .7 Street Number Direction Y" Str-'1t Na a CT i JCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3�1 0 Street Number Street Name <br /> CITY �i STATE G ZIP <br /> `Y' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2P�� 32 8- o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECSJESTOR <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAME PHONE# EXT. <br /> 5 to <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C I STATE ok 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 /> I also certify that I have prepared this applicati9-0-�at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, $TATE land FEDERAL laws. _, C <br /> APPLICANT'S SIGNATURE: � ��r IY�+ DATE. <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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, 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 pro 1��1 l0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> C� �P(� ��� S'�N✓o� 2411 <br /> N EA�NVIR p VIN fTyOFCOpgR��Nn' <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O [ P/E: <br /> Fee Amount: ' Amount Paid9/ � Payment Date S// <br /> Payment Type r Invoice# Check# Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />