Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 ff�000 ��3 s[NO q13o <br /> OWNER/OPERATOR <br /> Y C7. ,LQ \'^4..r <br /> C, CHECK If BILLING ADDRESS <br /> FACILITY NAME " ,- 1' <br /> M�uw�;r ;kPiz2ci <br /> SITE ADDRESS <br /> IDLg <br /> Street Number Direction Streel Name `C \ Ci ZipCodet <br /> HOME Or MAILING ADDRESS (If Different <br /> ��from Site Address) <br /> M1 w1 �)nUp SlreM Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (5(w Sta - ---�C\a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> A"w� S 11 1CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# En. <br /> ,5�ra�a.✓\ i\`���s '2-�t S�-"1r12 <br /> HOME or MAILING ADDRESS <br /> CITY 1 �\ @ STATE C/X ZIP <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 FE ORAL laws. <br /> APPLICANT'S SIGNATURE: DATE: - 101 <br /> U <br /> PROPERTY I BUSINESS OWNER 11 OPERA /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY Proof of authorization t0 sign Is required Tire <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> to 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. RECEIVED <br /> TYPE OF SERVICE REQUESTED: Q' GUnSQ� RECEIVED <br /> COMMENTS: <br /> Ow Ol lw o I fu l fho n MAY 18 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: [ 16 1 <br /> ASSIGNED TO: Sk*hanle <br /> Ve��lrl L rel EMPLOYEE#: DATE: /S IC/� I� <br /> (FeeDate Service Completed (If already completed): SERVICE CODE: SGU PIE: 11/)(0 <br /> Fee <br /> Amount: . Amount Paid )6�2 Payment Date <br /> Payment Type G y_ Invoice# Check# \ r 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />