Laserfiche WebLink
SAN JOAQUI160UN'l'Y LNVIRONMGNTAL HEA LODEPAR'1 TENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5'0o -32 07c-g <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS{�(!31 <br /> FACILITY NAME • <br /> SITE ADDRESS S 7C13 A, <br /> � c <br /> De_ �o, '.vt. I ►� y �� �` <br /> street Number OIreCII.n Street Name CII ZipCodc <br /> HOME Or MAILING ADDRESS (It Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (1a ) EIS - 79 6-1 <br /> CONTRACTOR/ SERVICE REQUISTOR <br /> R0 ESTOR <br /> J � CHECK It BILLING ADDRESS <br /> 1°iL �V .� <br /> BUSINESS NAME PHONE# EXT. <br /> Sir's Z� 3 �- /Sy <br /> HOME or MAILING ADDRESS FAX# <br /> s w - Deli vr. ( ZO) <br /> CITY STATE ` ZIP <br /> C l <br /> BILLING ACKNOWLEnGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTl1 DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to rue 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,S ATE and FEDERAL laws. � <br /> APPLICANT'S SIGNATURE: DATE: 0 4, P 3 <br /> PROPERTY/BUSINESS O WNH.RIY51 OI,ERATOR/MANAGE ❑ OTHER AtrrilORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY_proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: <br /> COMMENTS: RECEIVED <br /> FEB 6 2003 <br /> SMI JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> EM'AMMENTAL HEALTH DIVISION <br /> APPROVED DY: EMPLOYEE#: 4;19-7;� DATE: .� � <br /> ASSIGNED TO: � D v EMPLOYEE#: � DATE: O� <br /> Date Service Completed (if already completed): SERVICE CODE: 5 2Z P E: <br /> Fee Amount: FAmount Paid - Payment Date ��, � <br /> i <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />