WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQUESTOR REQUESTOR e V I N Co ✓� F I CHECK It BILLING ADORES5� BUSINESS NAME_ _ L 611, N (/IU " I `�'n C f PM — Rq � I E� HOME or MAILING ADDRESS FAX# 1 ) CIN c �-. -. C, ^ ' STATE CA zip C 2 Di� 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. 1 also certify that 1 have prepared this applic tion and that they'eti` to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards S FE andaws. / / APPLICANT'S SIGNATURE: r/ilW/J DATE: `� PROPERTY/ BUSINESS OWNERO PMAT0RI MANAGER ❑ OTHER AUTHORIZED AGENT ],/APPLICANT is not the BILLyG PARn proof of authorization to sign is required Tote AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: COMMENTS: V MAR 112022 HEALTH 'IG, /, f� ,`+C7 C v EMPLOYEE #: DATE: I�UU�V„r v „alr. EMPLOYEE #: DATE: J t ompleted (if ady Completed): aAmount: SERVICE CODE: [� �� PIE: flJU — Amount Paid 5'� Payment Date 3J� �,Z�� G� Invoice # # /3 - 4 B3 q �- Received By: EHD 48-02-025 3< y ( -�V Ly SR FORM (Golden Rod) REVISED 1111712003 2-2-- CONTRACTOR L