Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> 031 LH� L SIM'S 01-:v-� <br /> OWNER/OPERATORIrti <br /> e C) CCA ✓AIU/� ���HECK If BILLING ADDRESS <br /> FACILITY NAME I SW (ZD0LS1C( <br /> SITE ADDRESS U A 10.-1 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10-1 OI0t,�Q -� <br /> Street Number _J Street Name ,J <br /> CITY ( STATE ol ZIP �s2C) 5 <br /> PHONE#1 V En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ext BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 withthis 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 FEDERAL laws. II <br /> APPLICANT'S SIGNATURE: L' ` DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> if APDL/CANT is not the BILL/NG 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 <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 the same time it is <br /> provided to me or my representative. ` I/��" <br /> TYPE OF SERVICE REQUESTED: V aKl c(t C'wnaw vc1 <br /> COMMENTS: <br /> ACCEPTED BY: r-J EMPLOYEE#: DATE: <br /> ASSIGNED TO: I/ i EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: / Amount Pal Payment Date Qla 1Z <br /> Payment Type Invoice# Check# R ceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />