Laserfiche WebLink
SAN JOAQ C <br /> OUNTY ENVIRONMENTAL HEALTHINEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> vr� to a115 <br /> �1�r",5 `3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> � V,!L--) �), -f!�La+ <br /> FACILITY NAME ' �ir C) (. L1 i (O 1/'Lt <br /> SITE ADDRESS � W �f \-G -�O c)6-1 (!�' Zl'l0 <br /> Street Number Direction Street Name J C' ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Ye" <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME v�! �j` � PHONE H ,^--CIS <br /> L` ExT <br /> HOME or MAILING ADDRESSFAx x"�O ~ /\� . <br /> C u � i) <br /> CITY ` STAT" 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 <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 JOAQu[N <br /> COUNTY Ordinance Codes,StandTA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �lC�a _ DATE: <br /> 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPARTY,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: I <br /> REC <br /> COMMENTS: <br /> AUG 1 5 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: I� g V DATE: ell 510 P <br /> ASSIGNED TO: r` i EMPLOYEE#: ' DATE: ` O <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ' <br /> Fee Amount: 10'0 Amount Paid 15 Payment Date l SI <br /> Payment Type Invoice# Check# CJ 1 3 Li Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />