SR0084032 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property p not -A --ILK �" pro FACILITY ID # SERVICE REQUEST # BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS OW R / OPERATOR L b � vl 1 P (� O L i n - \ , I ; w i • , L"t K t i T` 1�[ CHECK If BILLING ADDRESS FACILITY NAME ACCEPTED BY: G/, SITE ADDRESS DATE: $ �' �"L litee EMPLOYEE #: Pe 52! �- Street Number Dlrectlon Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Payment Date S� Payment Type j Invoice # Check # �Z �J tP� Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT• ( 11 APN # LAND USE APPLICATION #�� ?tae'-Lf LOP to PHONE #2 EXT. 40 G — BOS DISTRICTLOCA �=� ONM ( ry OU IV CONTRACTOR / SERVICE REQUESTOR RTMEN RE UESTOR p not -A --ILK �" pro P. , ` CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX # L 24-HOUR CITY STATE ZIP ' BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. N APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER V OP RATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 0-6 C4 L&AA kP415 p not -A --ILK �" pro COMMENTS: tOc7I �� 6e1 ;,skillf6e( �Yl fhlc e4s} Side 4 i i-se0ence• vets ' Yeo lerch 1 fines it (209) lCALL FOR INSPE 24-HOUR op REQUIRED. ACCEPTED BY: G/, EMPLOYEE #: DATE: $ �' ASSIGNED TO: A EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Llo7O� Fee Amount: I �� Amount Paid 15�. �� Payment Date S� Payment Type j Invoice # Check # �Z �J tP� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 953-7697 CTION. NOTICE