Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Po�� 3 �� SR00 �2�53 <br /> OWNER/OPERATOR <br /> n CHECK If BILLING ADDRESS <br /> FACILITY NAME /./ <br /> d LL <br /> SITE ADDRESS ��(fQl V4ock-Eoo C'R�SZoS— <br /> �O Street Number I Direction Street Name city zip Code <br /> HOME or MAILING ADD ESS (If ifferent from Site Address) <br /> T/ p/ <br /> l O'�Gi U Street Number 6A <br /> CITY STATE ZIP <br /> '5 '0C kEoV) 6V4\ ZoZ <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR OD <br /> c7 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> LY {/lam ( ) <br /> CITY ,C 6 / U STATEL /I ZIP 67 C Z 05 <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 FvDERAL laws. <br /> APPLICANT'S SIGNATURE: fl��''/ //t 'BATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> 1f APPL1CANTisnotthe BlLL1NGPARTYproofofauthorization 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 environmentaVsite 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: <br /> sAN�oT 191020 <br /> Ht 7AQUIN <br /> 8' OAUCNO <br /> ACCEPTED BY: � ' t-U EMPLOYEE#: DATE: <br /> ASSIGNED TO: J EMPLOYEE#: DATE: 1 <br /> Date Service Completed (If already completed: SERVICE CODE: I P 1 E: <br /> Fee Amount: l� L Amount Paid 15a i-- Payment Date GO G� <br /> Payment Type Invoice# # I CJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />