Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYYjID SERVICE REQUEST# <br /> -FA <br /> ?7-1)IV4OWNER/OPERATOR (( ((�� <br /> uU Y\4Vvt li(-h S� CHECK If BILLING ADDRESS <br /> FACILITY NAME TO A-Ve t-( ,�* <br /> SITE ADDRESS 1-3 L <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or AILING ADDRESS (If Different from Site Address) <br /> —1I 1'01 Kz(SG V I Street Number Street Name <br /> CITY S 1 UU�-tvv\ STATE ZIP <br /> 1U <br /> PHONE#1 Exi. APN# LAND USE APPLICATION# <br /> V101,) SC1N ,W �2SU <br /> F <br /> HONE ii2 EXT. BOS DISTRICT LOCATION CODE <br /> ( —1�ul 1[ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 11 Y 1 IU ti S L CHECK if BILLING ADDRESSEY <br /> r� TJI PH <br /> BUSINESS NAME ONE# EXT. <br /> ) gqy_ 2 SO <br /> HOME or MAILING ADDRESS � (�nFAX# <br /> I G ( ) <br /> CITY {��, STATE ZIP y L <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 or <br /> 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 I <br /> APPLICANT'S SIGNATUR DATE: 3I Z II <br /> PROPERTY/BUSINESS OWNER 7 OP BATOR/MANAGER L'Y OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> - 18 <br /> TYPE OF SERVICE REQUESTED: RMY T <br /> COMMENTS: <br /> MAR Z 5 2019 <br /> C/I' O 0uJ/IQ,tS�/1 r N y40 tNCOu <br /> �i�. � Him p P�T�Nrr <br /> Grju� <br /> ACCEPTED BY:L 01 <br /> j A r EMPLOYEE#: l� �j DATE: - 5 'c <br /> ASSIGNED TO: V EMPLOYEE M UUU ✓� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: J 2 <br /> Fee Amount: () Amount Pai ! D� Payment Date - —/ <br /> Payment TypeTi'�� Invoice# �q7 7J4; Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ��p4 i2(VLf LA <br /> S <br />