Laserfiche WebLink
2-01 <br />SAN JOAQOOUNTY ENVIRONMENTAL HEAL ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />ked <br />had U11 <br />CCB <br />RLftw <br />OWNER / OPERATOR <br />FAX # <br />HOME or MAILING ADDRESS <br />DATE: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME TWO <br />Ac i <br />ZIP <br />STATE CA <br />SITE ADDRESS R-1 <br />E <br />! /�T11N-P F ,b <br />ll l C71 U <br />`.L <br />Street Number <br />Direction <br />Street Name <br />cityVC" <br />Zic..JCCodJeC.J <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Invoice # <br />Check # S p ✓l ✓� <br />Street Number <br />Received By: <br />Stre <br />CITY <br />STATE <br />PHONE #1 <br />( ) <br />EXT. <br />APN # LAND USE APPLICATION # <br />FEB 2 6 20 JU <br />PHONE#2 <br />J <br />EXT• BOS DISTRICT ENVIR �fG{ � LTI 1 <br />( ) <br />CQ <br />� LI 11Yll It VLlIVJVLV <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />a1TL1LC0ft1fa=& <br />CHECK If BILLING ADDRESS <br />Me), <br />BUSINESS NAME <br />CCB <br />RLftw <br />PHONE y EXT• <br />1 <br />FAX # <br />HOME or MAILING ADDRESS <br />DATE: <br />ASSIGNED TO: <br />(&3) <br />CITY <br />ZIP <br />STATE CA <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 FEDERAL laws. /� <br />APPLICANT'S SIGNATURE: w f ILT V DATE: <br />� 26-10 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Lli ff—PhLck"TIIE, <br />If APPL/CANT 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 sam time it is <br />provided to me or my representative. EN <br />vAYM...�n <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS:Ir <br />CCB <br />RLftw <br />ACCEPTED BY: <br />EMPLOYEE#: LGA <br />✓✓ <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />G <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: <br />Amount Paid_Sty <br />Payment Dated 2(v C7 <br />Payment Type <br />Invoice # <br />Check # S p ✓l ✓� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />