Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL REALTH DEPARTMEN <br /> ., SERVICE REQUEST <br /> Typi3`of Business or Property FACILITY!D# SERVICE REQUEST# <br /> —s-,,,q6P —7 = . <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> l TOU :1 <br /> SITE ADDRESS LOQ ✓r�yb <br /> Street Number rec me Ci <br /> HOME or MAILING ADDRESS (if Different from Site Address) -'2--'7 S Gq� <br /> Street Number tr et Name <br /> CITY � � ATE hp 's <br /> ` PHONE#1 <br /> EXT. API# LAND USE APPLICATION# V <br /> s t2��► Zc�3 -.s33� C�� � �' <br /> PHONE#2 ExT. BOS DISTRICT LOCAIF104 CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> Y REQUESTOR CHECK If BILUNO ADDRESSE] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING,ADDRESS FAx# <br /> CITY STATE ZIP <br /> 1 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some. <br /> acknowledge that all site and/or project specific ENv1RONNtFNTAL HEALRI DEPARTiff,NT hourly Charges associated with this project <br /> i, <br /> t� <br /> or activity will be billed to me or my business as identified on this fo1111. <br /> I also certify that 1 have prepared this application and that the work to be perfortned will be done in accordance wit68 ' A'' x ` ` " <br /> COUNTY Ordinance Codec,.Standards,STATE an FERE: lay <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROYERTV/BUSINESS OwNERt]a OPERATOR!MANAGER OTIIER AUTHORIZED AGENT❑ _ <br /> If APPLICANT i,c riot the Bt umc,.l'.aftTY.proof of authorization to sign is required Title <br /> AUTIIORI7 ATION TO RELEASE INFORMATION: When applicable,1,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 C01 rNTY EN VIRONMTiN1TAL HEALTH DEPARTMENT as soon as it is available a��T 1VI C e it is <br /> 1 provided to me or 1ny representative. RECENVED <br /> TYPE OF SERVICE REQUESTED: bCA4 -H Z013 <br /> M AT <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /tel EMPLOYEE#: 73 DATE: <br /> ASSIGNED TO: ,` ` EMPLOYEE#: �� '],.�� DATE: <br /> i; <br /> i Date Service Completed (if already completed): SERVICE CODE: P i E: <br /> i <br /> i Fee Amount: �s` Amount Pa' �,0� Payment Date 5 7/3 013 <br /> Payment Type V Invoice# Check# � Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />