Laserfiche WebLink
L_ <br /> $AN JOAQUU&uNTY ENVIRONMENTAL HEALTH fWARTMENT <br /> ad SGC 8 SERVICE REQUEST <br /> Type of Business 1u Pfrty FACILITY ID# SERVICE REQUEST# <br /> -� <br /> OWNER/OPERATOR <br /> rCHECK If BILLING ADDRESS❑ <br /> FACILITY NAME -Iv? <br /> �`/i <br /> J <br /> SITE <br /> `AD�DIRESSO�L� 1� ( qG��12 <br /> 1 v Street Number i/recVtfon t ame 1 C -JZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE V EXT• APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1� <br /> J/1(' �,.C ' (J�, CHECK If BILLING ADDRESS <br /> BUSINESS NAME -- `vlV PHONE# Err. <br /> SII{ �7 1 vA 1 1' J I ` L his- I0"i ; <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1� 0 C , v STATECA- ZIP Z <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,STATE and FmERAL 1 s. / <br /> APPLICANT'S SIGNATURE: DATE: � G / ' <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT-lf�sly�1 <br /> If APPLICANT is not the BILLING PAR71%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. PAY <br /> TYPE OF SERVICE REQUESTED: , /l~ <br /> CoMMEws: AUG 2 0 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 2J C' Amount Paid Payme Date Z$ <br /> Payment Type 7 Invoice# Check#�d Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />