Laserfiche WebLink
SAN JOAQU OUNTY ENVIRONMENTAL HEAL DEPARTMENT <br />SERVICE REQUEST <br />_ .tI iness or Property <br />hkw <br />FACILITY ID # <br />'�)� 0(& - <br />BUSINESS NAME <br />SERVICE REQUEST #1� . <br />OWNER <br />OWNER / PERATOR VrV <br />FACILITY NAME n 1 ^� (/L` 1 <br />P NE# <br />CHECK If BILLING ADDRESS ❑ <br />SITE ADDRESS <br />/ Street Number <br />Direction <br />! <br />J Street Name <br />EMPLOYEE #: Y ✓ J 3 <br />1 <br />i � <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SERVICE CODE: % 79 <br />Street Name <br />CITY <br />Fee Amount: <br />Amount Paid <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />Payment Type <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />,N CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO d <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />RECEIVED <br />JAN 5 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMEgr- <br />ACCEPTED BY: <br />4�7EMPLOYEE <br />P NE# <br />Exr. <br />HOME or MAILING ADDRESS <br />ASSIGNED TO: <br />FAX# <br />EMPLOYEE #: Y ✓ J 3 <br />CITY <br />STATEO <br />ZIP G�(5Z45 <br />Iv <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 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, Standar(S',STATF.1and FEDERA laws. I �j <br />APPLICANT'S SIGNATURE: V DATE: <br />PROPERTY/ BUSINESS OWNER❑ 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. <br />TYPE OF SERVICE REQUESTED: f <br />COMMENTS: <br />n /? <br />RECEIVED <br />JAN 5 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMEgr- <br />ACCEPTED BY: <br />4�7EMPLOYEE <br />�-j // <br />#: / v <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: Y ✓ J 3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: % 79 <br />P I E:d.30 <br />I <br />Fee Amount: <br />Amount Paid <br />--71? <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By <br />10 EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod <br />