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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I)EPARTME <br /> NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS �+ <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CJP1 ZIP CAS2118 <br /> PHONE#1 E)cr• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4 �C CHECK if BILLING ADDRESS❑ <br /> 7O PHONE# Ems' <br /> BUSINESS NAME ('M6 ,25_ WU <br /> HOME or MAILING ADDRESS FAX# <br /> �. O • W) (C1-) 3l - \`-I <br /> CITY \ C _ _ STATE CA ZIP ON4,,1�q <br /> IJ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of Sam <br /> acknowledge that all site and/or project specific ENvIRONMENl"AL 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,Stan TATE and FEDERAL laws. Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 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 avail is <br /> provided to me or my representative. ( (.S I ' F f D L , Dl <br /> TYPE OF SERVICE REQUESTED: <br /> AU <br /> COMMENTS: , <br /> 2ooa <br /> ENVIRONMENT HEALTH <br /> UIN GOUNN PERIMMSERVICES <br /> SW 30A ONDE MENTAL T <br /> Ei,N1P PARTMEN <br /> Ep,ETH I <br /> ACCEPTED BY: �1�- �� EMPLOYEE#: 32 DATE: <br /> L u <br /> ASSIGNED TO: c I EMPLOYEE#: C LF 7-72- DATE: / ((( qtr <br /> Date Service Completed (if already completed): SERVICE CODE: ! P i E: 3 <br /> r Amount Paid Payment Date 6-� <br /> Fee Amount: 3 f > 6 � , -1 <br /> rj <br /> Payment Type I " ) Invoice# Check#3 �� �4r Q Received By: V LT <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> �;.�-�----" <br /> REVISED 11/17/2003 <br />