Laserfiche WebLink
SAN JOAQUIIoUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2ez4y'. 061 C�L�(� 5( C67��1 ,7)-- <br /> OWNER/OPERA R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> - <br /> Street Number Direction Strtiet Name city <br /> ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#') EXT, <br /> API# LAND USE APPLICATION# <br /> PHONE#1 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f,, I /IN �� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> HOME or MAILING ADDRESS FAx# <br /> G� --.;?,A / ( ) <br /> CITY LS STATE zIP 9CJ '74, J <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 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT g� <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 DFARITIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> /,e) <br /> OF SERVICE REQUESTED: � l sc� ZDV <br /> eIV-IVimpCOMMENT$: 1/ <br /> �� r <br /> � FEB <br /> ySpHME oU T?' <br /> eALr/y pep Nrq <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: ef i EMPLOYEE M DATE: 1 , <br /> Date Service Completed (if already Completed): SERVICE CODE: I P I E:2 <br /> Fee Amount: 4 1 T) CID Amount Paid $ Payment Date "7— 2 I <br /> Received By: <br /> Payment Type I S& Invoice# Check# y Ip7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />