Laserfiche WebLink
" <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHIRPARTMENT i <br /> SERVICE REQUEST S o S 3 Z <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> Q U l (n e•RL4 <br /> OWNER/ PERATOR <br /> I e 4 -V C 1 �n/ CHECK if BILLING ADDRES <br /> FACILITY NAME - x l <br /> l E'L'ck <br /> SITE ADDRESS 1.2 c If `C wes� �--1.rC l - S v CCx�n ��O <br /> Street Number DI tion treat ame CI 2f Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) � 3"� 2 `� <br /> < __ ' Street Number " 't l Street Name <br /> CITY STATE CA <br /> ZIP , <br /> enY� <br /> PHONE#f EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATIOfI CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> ( L )( — / <br /> CITY STATE 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,SATE and� E L laws. <br /> APPLICANT'S SIGNATURE: DATE: P� <br /> PROPERTY/BUSINEss OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. , lw;I "1 <br /> TYPE OF SERVICE REQUESTED: Us--r l r I /^J Cy /) Z 4 ( Ie R F C'E <br /> COMMENTS: <br /> JAS 2 8 N0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �> (����( EMPLOYEE#: / DATE: C <br /> ASSIGNED TO: Q AJ EMPLOYEE#: DATE: ( CO Y <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 3 , <br /> Fee Amount: c'-C% Amount Paid lt� a Payment Date 8` <br /> Payment Type Invoice# Check'# 1;)L-1 Q p U Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />