Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FAcIUTY NAME lit ZZ �n/ _ t 1 <br /> SITE ADDRESS ` (� Y w s ST ^V4 ra sore Q � � O <br /> Street Number Direction Street Name C Zi Code <br /> Ho Or �NG ADDRESS (if Different from Site Address) <br /> yumber StreetName <br /> CITYri STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> (WA4A Air <br /> PHONE #2 EXT. , BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME T \ V u ` V PHONE # G� .� E"T <br /> HOME or MAILING ADDRESS FAX # <br /> l ) <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 <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, S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: WA DATE: '� / 61 <br /> PROPERTY / BUSINESS OAVNERVKO� <br /> AERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLicANT is not the BrLLINC PART) 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 and at the same time it is <br /> provided to me or my representative. Pq Y <br /> fit <br /> TYPE OF SERVICE REQUESTED: I ! � Cii f/ <br /> -8 I�J-::: <br /> COMMENTS : <br /> SEP ' 4 Zp10 <br /> SAN JoAQUI <br /> i hey` VIRONM COUNT <br /> T D�pARTM&/V <br /> At �� .. EMPLOYEE #: DATE: <br /> ACCEPTED BY : <br /> ASSIGNED TO : �' N EMPLOYEE #: DATE: C, <br /> Date Service Completed (if already completed) : SERVICE CODE: 7 PIE: y <br /> Fee Amount00 Amount Paid � , �� Payment Date <br /> Payment Type Invoice # Check # // �Z56t�lo4 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 / 17/2003 <br />