Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> �,� , CHECK If BILLING ADORESSE] <br /> FACILITY NAME <br /> L✓ Z /t A u <br /> SITE ADDRESS <br /> "I StreJat N'um�bYeYr Direction Street Name CN fi Code <br /> HOME 09 MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE02 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOw CHECK If BILLING ADDRESS <br /> G_�>1 Q <br /> BUSINESSNAME PHO E# EKT• <br /> e, <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <br /> SH,MG 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, STATE and F W ERAL laws <br /> APPLICANT'S SIGNATURE:_ � DATE: LraLZ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I�'APPLICANT is not the BILLING PARTY proofojauthorization to signis 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 available and,at,(lt,C,�,a,�qe jiJ'tIC It Is <br /> . <br /> provided to me or my representative. 1^AN f&N* <br /> RECEIVED <br /> TYPE OF SERVICE REQUESTED: Y_ ;tLL'fq W <br /> COMMENTS: AUG 18 LU <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B t au M <br /> EMPLOYEE#: DATE: I 2,2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ota 1 E: UZ <br /> Fee Amount: 'Uu Amount Paid 67l S b Payment Date <br /> Payment Type V l tj Invoice# Greek# g 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />