Laserfiche WebLink
SAN JOAQUII�UNTY ENVIRONMENTAL HEALT PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Sb'. <br />FACILITY ID # <br />SERVICE REQUEST # <br />a�) <br />g 1-7 <br />FSB _ <br />6�11NER / OPE TOR <br />��� <br />CHECK If BILLING ADDRESS <br />HOME Or MAILING AdDRIESS <br />a�� V' [� ^ <br />� <br />FACILITY NAME V) /# /I 6 <br />SITE ADDRESS <br />l.�o< <br />� <br />)rjection ( <br />_City li <br />'h <br />Street Number <br />Di�' <br />Street N me <br />PIE: <br />Fee Amount: 2- <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Date �5 <br />� �r P71 h Vo rd Dr. <br />00 <br />Street Number <br />Street Name <br />CITYo �n10. b� <br />STATE ZAP <br />1 � - <br />C.l <br />PHONE #1 EXT' <br />APN # <br />LAND USE APPLICATION # <br />959-9 o0 <br />1 <br />11 <br />PH Z EXT. <br />( �, _�i�-15� <br />`-- (C <br />BOS DISTRICT <br />LOCATION CODE <br />n CONTRACTOR / SVRViCE REQUESTOR <br />REQUESTORF <br />C Ll/ <br />h <br />ft�) <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME a I doL <br />FSB _ <br />PHONE-# EXT' <br />11 1 <br />HOME Or MAILING AdDRIESS <br />a�� V' [� ^ <br />� <br />FAX# <br />org) +„ <br />CITY �/Ih <br />STATE Z — <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar ,STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ' -9/(L�DATE: J <br />PROPERTY/ BUSINESS OWNER LJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT-[/km'U LU ALS <br />IfAPPLICANT 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: <br />COMMENTS: <br />C f/ a <br />FSB _ <br />SAN,, 2005 <br />HEADIV <br />. 7A1IVrY <br />ACCEPTED BY: <br />EMPLOYEE #: �a y q <br />/ <br />ASSIGNED TO: M <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:( <br />PIE: <br />Fee Amount: 2- <br />Amount Paid 02 <br />- <br />Payment Date �5 <br />Payment Type <br />Invoice # <br />Check # <br />Re <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />