Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> \'v T c :A 5"() 6a(& i S <br /> OWNER/OPERATORK/� <br /> G CHECK if BILLING ADDRESS <br /> FACILITY NAME -1T- <br /> SITEADDRESS /I 1 1 e- /' I ' e-c� <br /> Street Number Direction Street Name CIt ZI Cotle <br /> HOME Or MAILING jADDRESS (If Differ t from Sit Address) _ <br /> Al It <br /> 1. Street Number Street Name <br /> CITY n \� S,TATE ,J <br /> ONE#i ExT. w\\ N# LAND USE APPLICATION# <br /> V!, <br /> Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 JoAQUm <br /> COUNTY Ordinance Codes,Standards, STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> r. <br /> PROPERTY/BUSINESS OWNER OPERA /11' NAGE' ❑ OTHER AUTHORIZED AGENT❑ <br /> If.4PPLIcANT is not the BILL/NGPABTY 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 HEALTB 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: O ,?L.-A,,J <br /> COMMENTS: <br /> RECENED <br /> DEC 21 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT' <br /> ACCEPTED BY: LL t>Ef Q� EMPLOYEE#: ��Z / DATE: y/ t Q <br /> ASSIGNED TO: EMPLOYEE#: Lf 7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S'Z3 PIE: <br /> Fee Amount--43 && ,0ol Amount Paid%541'6, z- p Payment Date / A I <br /> Invoice# d Rece ved By:Payment Type <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />