Laserfiche WebLink
` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fib© 22 J �1200�0(��1 <br /> OWNER/OPERATOR <br /> C ' CHECK If BILLING ADDRESS <br /> FACILITY 1 N1,"AllE C• i LXy.,,,,\ <br /> SITE ADDRESS ?-1 v �o�St ,N� YY1Yr1Qr�,Qr�C 2 2 <br /> Street Number Direction Sfraet Name c1tv Code <br /> HOME or MAILING 1ADDRESS (If Different from Site Address) <br /> i`n �O� �n U N O&V <br /> I v Street Number ^� 5Street Name <br /> CITY SI�/T O l p <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2uq )gi"l"l-(P?A 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> rl►�n oUwoYMOVIC corQ (004b <br /> HOME or MAILING ADDRE S FAx# <br /> I �3b�ov1te 130 Norte ( u ) <br /> CITY tlw11 STATE NJ ZIP Oto l Ld <br /> BILLING AC OWLEDGEMENT: 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE(-�.4 A La i DATE: . -2— <br /> PROPERTY <br /> PROPERTY/BUsINESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require Title <br /> AUTHORIZATION 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> AA <br /> TYPE OF SERVICE REQUESTED: v/n <br /> �N <br /> COMMENTS: A6.4 <br /> ZO <br /> AfAr28 2019 <br /> SAIVNVRE / <br /> AQ coN�Atr/ypMETqijjv <br /> ry <br /> ACCEPTED BY: cow EMPLOYEE M DATE: <br /> ASSIGNED TO: in EMPLOYEE M DATE:L� <br /> Date Service Completed (if already completed): SERVICE CODE: N01 1 <br /> PIE! <br /> 1. / <br /> Fee Amount: I 2 D Amount Paid �S�, _ Payment Date 5-/.2-g /I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 Cts q 1 5y�z SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Ft205Lf�Il� s <br />