Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST#' � � <br /> r� 3 `E 5 00�3�t lS <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> I <br /> FACILI NAME <br /> ';�e7cktialo / 3 <br /> SITE ADDRESS (,tl(,rf� C im S (�G k.� �9�j 2c. <br /> 5- Street Number Direction Street Name CI ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> —e— Street Number Street Name <br /> CITY STATE LP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (F/v) <br /> PHONE#2 E". BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> UJ.7 <br /> 1 V1R� CHECK IT BILLING ADDRESS <br /> BUSINESS NAME � f {{� PHONE# Ext. <br /> C k "-U O4J1 <br /> HOME or MAILING ADDRESS FAX# <br /> ( I <br /> CITY STATE 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 <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 DERA`L laws. <br /> APPLICANT'S SIGNATURE: 1 /t �'� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERlI!�, OTHER AUTHORIZED AGENT 13 n Lfti Y-?-A. ✓_ <br /> If APPLICANT is not the B/LLlNG 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. <br /> TYPE OF SERVICE REQUESTED: Q vQ or— CcT'L v-e v E' S <br /> COMMENTS: <br /> NOV 2 2 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ::::::[EMPLOYEE EMPLOYEE#: DATE: <br /> ASSIGNED TO: C EMPLOYEE M DATE: (-2,7 <br /> Date Service Completed (if already completed): SERVICE CODE: p� P I E: <br /> Fee Amount: i Amount Paid /� 2 — I Payment Date V( <br /> Payment Type n. Invoice# Pwa# p 7-T( Z Received By: <br /> EHD 45-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 r� <br />