Laserfiche WebLink
SAN JOAQUIN t—OUNTY ENVIRONMENTAL HEALTH DMARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> \25-\5 <br /> OWNER i OPE TOFj Q <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 1 <br /> SITE ADORESio a l e,�, \ <br /> treet Number Direction V Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> E#1) ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTfUC,TOR / SERVICE REQUESTOR <br /> REQUESTOR / n <br /> CHECK If BILLING ADDRESSO <br /> BUSINESS NAMEJ t/ PHONE# LAy� EXT.I-w <br /> AA <br /> HOME Or MAILING ADDRESS � � � FAX# ) <br /> CITY \ \ `� V `v`Cw STATE ZIP <:7' <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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 p formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA a DERAL laws. / <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNEIR 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VIA <br /> COMMENTS: �` <br /> `(O o <br /> SAN,, 6 2019 <br /> ENV�AQU/N <br /> h�CTy OA1 FNTq Nn' <br /> ACCEPTED BY: C�(I V�0/ ��V�,7-1 EMPLOYEE#: �tl t DATE: <br /> ASSIGNED TO: G �C \\�i11�7 a �Xi L EMPLOYEE#: g/G , DATE: \ �\\ci <br /> Date Service Completed (if already competed): SERVICE CODE: ( PIE: `q� <br /> Fee Amount: \�Z. pV Amount PA ls� Payment Date <br /> Payment Type Invoice# Check# fb ��� ef Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />