Laserfiche WebLink
SAN JOA V'iN COUNTY ENVIRONMENTAL AL HEALTH U`tPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPhFawt4 �kw � <br /> S CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS G" m�nqj W Rl *.AUL � S3 <br /> Zip Code <br /> HOMEQr MAILING ADD ES c(If Differt from Site Address <br /> �'= /I/ <br /> I Street Number Street Name <br /> CITY Iip na CA- Z9 533 fo <br /> PHONE#� EXT. 7# ^ 1-7-2-1 <br /> D LAND USE APPLICATION# <br /> cHONE 3!v- ?,3s5 L l <br /> PHONE#2 EXT. BOS DISTRIC LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Shawn Garc�a�S <br /> BUSINESS NAMEPHO ExT. <br /> Fl fh ('140 o0 3/0--736-5 <br /> HOMfor MAILING ADDRESS FAX# <br /> CITY nA S&A 7F <br /> AAF ZIP l !'3o <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 /> 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 /> 40/0-- � <br /> APPLICANT'S SIGNATURE: 4DATE: "9 <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, 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: AA <br /> PAYMENT <br /> COMMENTS: <br /> FEB 0 5 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: A.„ EMPLOYEE#: QO®� DATE: 7 t("' <br /> ASSIGNED TO: f, EMPLOYEE#: / `1 DATE:� �l <br /> Date Service Completed (if already completed): SERVICE CODE: b6 PIE: 1 a 3 <br /> Fee Amount: Z 0D Amount Paid I Payment Date <br /> Payment Type Cq S Ll Invoice# Check# Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />