Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # Em <br />SERVICE REQUEST # <br />FAX # <br />CITY STATE ZIP <br />ACCEPTED BY: rYvt -Cse, O <br />EMPLOYEE #: <br />DATE: b 21 —2 <br />ASSIGNED TO: C tU'Z-J 0 <br />EMPLOYEE #: <br />1 <br />OWNER/ P RATOR <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/ !/ �L iL �G /'� r/ <br />Fee Amount; <br />CHECK if <br />BILLING ADDRESS� <br />FACILITY NAME <br />O <br />Payment Type <br />Invoice # <br />d•L/2 � 11 6/--C !' G <br />Received By: <br />SITE ADDRESS <br />"L) 99 <br />�- <br />S e AGK <br />3 Street Number <br />Direction <br />/ <br />Street Name <br />Zipda <br />HOME or MAILINqG ADDRESS (If Differ nt from Site Address) <br />3 oL S (J <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXr. <br />APN # <br />LAND USE APPLICATION # <br />% / G' <br />PHONE#2 EXT. <br />( ) It <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />- CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Em <br />HOME or MAILING ADDRESS <br />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 <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 <br />COUNTY Ordinance Codes, Standards, <br />IiYl&i VU1R1 ail <br />PROPERTY/ BUSINESS OWNER❑ <br />YAPPL/CANT is not the <br />lid that the 9" to be performed will be done in accordance with all SAN JOAQUIN <br />FEDERAL JAVS. <br />k//It DATE: <br />r0 A \' ❑ � OTHER AUTHORIZED AGENT ❑ <br />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 environmQ assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available it is <br />provided to me or my representative. C <br />TYPE OF SERVICE REQUESTED:AI <br />COMMENTS: <br />HE71.Ty0 CC OVn, <br />ENT <br />ACCEPTED BY: rYvt -Cse, O <br />EMPLOYEE #: <br />DATE: b 21 —2 <br />ASSIGNED TO: C tU'Z-J 0 <br />EMPLOYEE #: <br />1 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount; <br />Amount Paid <br />� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />NWW4223 <br />SR FORM (Golden Rod) <br />