Laserfiche WebLink
SAN JOAQUIN GUUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T <br /> R/OPERATOR -- <br /> rl <br /> P p,'e �,\ ( NO-,7 CHECK if BILLING ADDRESS <br /> FACILITY NAME Z v\/AF <br /> S,��T^[{F ADDR/ESS ,qui ( I ' 1 �]`� ' t/ StreetNumber Direction ��"1 � tN�� W v`\ � ci �D�T�� e <br /> H E Or A IN!GADDRE rent from <br /> Site Aess�' fUN S `' ( _ <br /> Street Number Street Name <br /> CITY <br /> 70 `� O v i t $T TE 5 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> p H0E;Z � � / ��ExT. BCDS DISTRICT LOCATION CODE <br /> (C j CONTRACTOR SERVICE PXQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEL , PHONE#/t^ (1(1,4c�/71 -38'� <br /> J <br /> HOME or[AAI IN A RESS / .� - FAX# <br /> CITY /BOG /I �) TATE ZIP <br /> BILLING AChNOWLEDGEIIAENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ,{ <br /> APPLiGAN T'S SIGNAT UR -A/E /- �"/ C/Z DATE: 0 '/� <br /> PROPERTY/BUSINESS OWNER 6 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, 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 /> to 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:COMMENTS: <br /> JUL 01 20ie <br /> SA ENV ROMENT <br /> A COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: G p G, EMPLOYEE#: DATE: <br /> ASSIGNED TO: [/ EMPLOYEE#: DATE: / <br /> Date Service Completed (if already Completed): SERVICE CODE: SC Ll I P IE: Lj <br /> I 3 <br /> Fee Amount: Amount Paid 3 0 •d Payment Date <br /> Payment Type Cwt Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />