Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />0 SERVICE REQUEST 6 <br />Type of Business or Property <br />on <br />BUSINESS NAME <br />L(tHOME <br />FACILITY ID # <br />cz3 <br />SERVICE REQUEST # <br />s��v <br />OWNER / OPERATOR <br />� <br />CITY , STATE /i� ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAM nonn--) <br />N!\f\,\ <br />ffnf�j - <br />—t <br />SITE ADDRESS (�.o <br />Street Number <br />W <br />Direction <br />�-n ftmn <br />Street Name <br />DATE: <br />u� Cit <br />1iJZiC-Code <br />HOME or MAILING ADDRESS (If Different from Site Address) (v <br />Street Number <br />Street Name <br />CITY <br />Amount Paid -f� 3 <br />Payrn Date <br />STATE ZIP <br />PHONE #1 EXT. <br />(L0 <br />Invoice # <br />APN # <br />Check # 13-7 <br />LAND USE APPLICATION # <br />PHONE #Z <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />L(tHOME <br />PH NE ll�/f. 0661 ExT. <br />or MAILING ADDRESS % <br />Loa 0) � � � <br />FAx <br />( ) I - 65f2 - <br />CITY , STATE /i� 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 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 />APPLICANT'S SIGNATURE: �� DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Q PT - {ea r tiw J <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: J <br />COMMENTS: To �mka I ►�L \ly ftrV ) -Z� <br />fhv sfiv �P9rcc� �f �c;r- �'cx <br />�C• 5.0. <br />ACCEPTED BY: <br />EMPLOYEE #: Z <br />DATE: u <br />ASSIGNED TO: <br />EMPLOYEE #: MIC7y <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P 1 E: <br />Fee Amount: ) S . <br />Amount Paid -f� 3 <br />Payrn Date <br />Payment Type <br />Invoice # <br />Check # 13-7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />