Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />d SERVICE REQUEST <br />Type of Business or Property <br />Nm�' <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />All a <br />3 <br />Z��J <br />1/0'N <br />' CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />r� / <br />� � Y <br />FAX_#�/ <br />SITE ADDRESS p ( <br />Street Number /Direction Street Name– ��� <br />�Gfi' Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Addres ) <br />6 <br />Street Number <br />/ I/"' St�6 tame <br />CITY <br />Lk <br />ASSIGNED TO: NA t U Ems_ <br />TE v ZIP <br />U� C, 5 / C) <br />PHONE #1 ExT. % <br />( - ) 3915-01/10/ �/ [ <br />`f <br />APN # <br />z 2! -1.5a-©% <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />SERVICE CODE: ( (v <br />BOS DISTRICT5 <br />LOCATION ODE <br />�J CONTRACTOR /SERVICE REQUESTOR � <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE <br />3 <br />Z��J <br />1/0'N <br />eD <br />cJ / <br />HOME Or MAILING AD16SS �[ <br />FAX_#�/ <br />C% <br />r <br />( ) <br />CITY STATE <br />ZIP <br />T - <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 ide ed on this form <br />I also certify that I have prepared this applicati 'd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd EDERAL laws. <br />APPLICANT'S SIGNATURE:3 <br />DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT K <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. p� <br />TYPE OF SERVICE REQUESTED: <br />('�'— <br />COMMENTS: <br />4&6 Q <br />V 2 <br />3 <br />Z��J <br />1/0'N <br />/y, �q0 ,N c <br />1i,tY <br />N�FAq <br />TM <br />r <br />ACCEPTED BY: L v t <br />EMPLOYEE #: D 7 2 <br />DATE: 2-3/0-7 <br />ASSIGNED TO: NA t U Ems_ <br />EMPLOYEE #: J,? <br />DATE: & Z 3 07 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ( (v <br />P I E: Z3 <br />Fee Amount: .)-C,(`( <br />Amount Paid <br />o�� �,1 <br />Payment Date 2-1 <br />Payment Type ✓ <br />Invoice # <br />Check # ' t <br />Received By: <br />EHD 48-02-025 '. ,fi F(SI�IVf (o)den`Rod)' <br />REVISED 11/17/2003 <br />