Laserfiche WebLink
g-ot GWYN 4\S2— <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />14,-e„.y fcc c.-:‘,.(7.7 <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR n Cirt ic Jr -7.6.44S CHECK if BILLING ADDRESS <br />FACILITY NAME <br />r v /6k H tIG '). 14,2, y 1 ee- CCee-itt ii y5a i6E/9 <br />SITE ADDRESS <br />1 113 0 Street Number Direction <br />L- '1,.-. 4.-- ve <br />Street Name <br />34-0c- Moil <br />City <br />c / c..2 _ 0 5 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P- 2_ / Street Number <br />r 1/4, 1/0_ S-1 <br />Street Name <br />CITY_ <br />5 40 (MOO <br />STATE <br />c#- <br /> ZIP <br />75-.20( <br />PHONE #1 EXT. <br />( 541 ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />611'fC k rn, '5 CHECK if BILLING ADDRESS <br />BUSINESS NAME . A <br />Mfrt:t71,e. ) 1/fr4,_ y i (4_ c/?,,,,,k7 PHONE # <br />( 376 ) 7 7.‘ <br />EXT. <br />37,2--i-y <br />HOME Or MAILING ADDRESS <br />. - 9) / th e.5 . <br />FAX # <br />CITY 5 .65,c, id 017 STAT., 4 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY BUSINESS OWNER Er OPERATOR! MANAGER El OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: (XII CV I (•/ 41 di 1 ipl iD#012) 6 <br />COMMENTS: <br />RECEIVED <br />JUL 1 5 2019 <br />SAN JOAQUIN COUNTY <br />ACCEPTED BY: [ ov rot c EMPLOYERALTHIRg=1NT DATE: 7 /1 /V /) <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Ciu / P / E: Aco3 <br />Fee Amount: $ 1 S.9_ 0 Amount Paid Payment Date --) i C CI <br />Payment Type v .a),_ je„,),) Invoice # Check # Received By fiza <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)