Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �D FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR 5 6 h /� <br /> CHECK If BILLING ADDRESS <br /> Gc f / � <br /> F - <br /> / 1 <br /> /� <br /> SITEADDRESS 730 S' Ca.I-(�nA/IA ,S kc,C.vl �b 9�7.203 <br /> Street Number I Direction Street Name C/I _ Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Ad,/dress) I cc <br /> 1/'6 VIL c, r"'Le Ov- Street Number / Street Name <br /> CITY STATE ZIP <br /> S G/' ci 216,7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (05) 3'�v 31 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � p��) r'^, <br /> M cv clt ./cvl CHECK If BILLING ADDRESS <br /> BUSINESS NAME �A�' 'W U• PHONE# EXT. <br /> CL 9J Cv k, f 2 c� - 319 <br /> HOME Or MAILING DDRESS FAx# <br /> CITY STATFyn LP �2G <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 orme a done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE �j DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA GER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT is nor the B/LLl"PART proof authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA O . 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: Rob, ;fo fd�zPqy <br /> COMMENTS: <br /> EI yF� <br /> AUG 1 i 2020 <br /> SAN N NVIRoNM COUNT y <br /> EALTy DEP ENT <br /> ACCEPTED BY: Lo <br /> !'-171 EMPLOYEE#: DATE: �y t To <br /> ASSIGNED TO: f t�f EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Paid (6a i Payment Date 00 P/2-0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />