Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 0 <br /> Type of Business or Property FACILITY ID # dmxe I SERVICE REQUEST # <br /> 2 lei <br /> 67 6 <br /> OWNER I OPERATOR <br /> l ( 1G CHECK if BILLING ADDRES <br /> Ue <br /> FACILITY NAME <br /> SITE ADDRESS �' ;r ' 7 <br /> Street Number Dir coon Slreot Nome CII Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP �/'� , At <br /> 7` <br /> Vt <br /> PHONE # 1 EXT APN # LAND USE APPLICATION # OCT1 , <br /> ( ► ted ' 1 ?02, <br /> PHONE #2 E%7 • BOS DISTRICT <br /> ( ► /�q � r °NMi5A� rrq�Nrr <br /> CONTRACTOR / SERVICE REQUESTOR MLZIVT. <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> �� �� « d41 < saMcIte <br /> BUSINESS NAMEPHONE # Ext , <br /> r�l <br /> HOME or MAILING ADDRESSFAX # <br /> 361 r k I ► <br /> CITY A .� r e , STATE CA 1 ZIP e?, <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 /> 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 FEDERAL laws , <br /> APPLICANT'S SIGNATURE : r / �0 / DATE : ! U J S I <br /> PROPERTY I BUSINESS OWNER 10 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DF. PARTMENT as Soon as it is available and at the same time it is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : [Jt ST /2Q�; ') <br /> COMMENTS : t , )) 1 � ' , n l Lv , <br /> G r" �G' �f � t L ll Fr S / fir ' - � r 7t S �cE1 � Zl � d <br /> CL� � h f Lc1 / F S ����J L�'"Leo/ d&' V� d ca (' 4or 4 e.) r , 7 % Os l �T / �ii.''�rrt <br /> � /' ' n <br /> V `1ELilJ /� � r ^� 1? l7 e / � �L! `' � {7I� � l� Liact G'r . luc' � � <br /> ACCEPTED BY : o' EMPLOYEE M DATE : U � � <br /> ASSIGNED TO : Y! v EMPLOYEE # : DATE : <br /> 00000 <br /> Date Service Completed (if already completed) : kL SEHVICE COUE : ` II <br /> Fee Amount : � c-co) Amount Pal Payment Date <br /> Payment Type Invoice # Check # g Received By : <br /> EHD 48-02.025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />