Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> / Ja,O <br /> Q.'WNER/(//OPERATOR <br /> .,16 C9 04-ctf`Z� ( 2 C L — 1 C/+' I / CK If BILLING ADDRESS <br /> FACILITY... 6� v"� l I Aac✓v^.9 v� 7 <br /> SITE ADDRESS CJ 13 W �� . I (t,�Imo' Pilr i� �� �Cj —0� <br /> Street Number Direction Street a e i Ci Zip Code <br /> HOME or IILING ADDRESS (If Different from Site Address) <br /> Zr T` Street Number Street Name <br /> CITY�TC / STATE ZIP <br /> T F526 -5 <br /> PONE#1 EXT APN# LAND USE APPLICATION# <br /> (ldD) 25.6 9360 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> (2 ) 6 9"y-4 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES OR <br /> CS �Gt// C/ A i ^ (J/ T v� �JJ CHECK If BILLING ADDRESS <br /> USINESS NAME�I BT�� ! �`i lam! wl Y PHO`N-Er[# EXT. <br /> OME or MAILING ADDRESS FAX# <br /> CITY 5—t-c STATE � ^ ZIP C?ISZ <br /> BILLING ACKNOWLEDGEMENT: 1, 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,S E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 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. p <br /> TYPE OF SERVICE REQUESTED: C&ASAAA ` J,157/V <br /> COMMENTS: Oct <br /> ,i 2019 <br /> hFUIN <br /> �ZRO�MF OIJop� NTY <br /> ACCEPTED BY: 4 CAOYZeV-tv EMPLOYEE#: DATE: I _1 o_1 <br /> CA <br /> ASSIGNED TO: q IT A('t, O C � EMPLOYEE#: DATE: I 'V vo <br /> Date Service Completed (if already completed): SERVICE CODE: D(O 1 P/E: <br /> Fee Amount: (C;5 2 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />