Laserfiche WebLink
SAN JOAQUIUNTY ENVIRONMENTAL HEALT46EPARTMENT <br /> 1 4 SERVICE REQUEST <br /> Type of B Siness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER PERATOR <br /> / CHECK If BILLING ADDRESS <br /> FACILITY NAM r 5 <br /> SITE ADDRESS (� „ <br /> ��') ��//7 /J' <br /> �StrNwfifber Direction 1 Sk¢� 7 Otfir7 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY a STATE ZIP <br /> PHONE#1, EXT. APN# LAND USE APPLICATION# <br /> ( f / 3G'�)--t-1 s <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTI <br /> (`(J e 4T- 1111AfL <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME I PHONE# EXT. <br /> ka <br /> (�4 -�7ik 41&/]Q,-- <br /> HOME or MAILING ADDRESS FAX# <br /> C=A Lit k61D r (-X3� <br /> CITY a STATE 71 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 busi s as identified on this form. <br /> I also certify that I have prepared th' app as <br /> and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, ST TE and FEDERAL 1 S. <br /> APPLICANT'S SIGNATURE: DATE: ? f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /A7 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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: FRFCEIVED <br /> COMMENTS: & `/`_ 1� EB 21 2008 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: GrJO> EMPLOYEE#: 2 L DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: ( <br /> Fee Amount: C,4 1 Amount Paid �, � Payment Date <br /> Payment Type Invoice# Check# -� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />