Laserfiche WebLink
SAN JOAQU#OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S.� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /� ��m� / Vd 106ez�– (0 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / CHECK If BILLING ADDRESS <br /> BUSINESS NAME ✓�Il� P26 <br /> # EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> PU. 60, (2il 3 5()6 <br /> CITY STATE /'R ZIP qf; , 'e <br /> L (/ <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, and DE wS. / <br /> APPLICANT'S SIGNATURE: ✓ V DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1CANT 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. PA\f&4 <br /> TYPE OF SERVICE REQUESTED: 1 1 VED <br /> COMMENTS: Qty 4 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTgL <br /> HEALTH DEP gRTMENI' <br /> ACCEPTED BY: EMPLOYEE#: Z DATE: <br /> ASSIGNED TO: EMPLOYEE#: ;gJHCl _ DATE: <br /> Date Service Completed (if already completed): SERVICE CooE: ` OD <br /> P 1 E: <br /> Fee Amount: C.n Amount Paid `S — Payn4nt Date 3 y <br /> Payment Type Invoice# Check# 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />