Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Dr�W 5f4* rA 0024L4 -Z SIS pp-b2t-( S 5 <br /> OWNER/OPERATOR n ` <br /> Ita-Wv�sO� CHECK H BILLING ADDRESS <br /> FACILITY NAME Inn Q <br /> fumfla <br /> SITE ADDRESS ( l 5 S ��`Q� �L� D.I q 6p-q0 <br /> Streat Number Direction l/tr L 1 Street Nama%H City �lLC <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SUeet Number Streat Name <br /> CITY STATE ZIP <br /> PHONE#1 ETI APN# LAND USE APPLICATION <br /> 4N )00'0wN451�W <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> 60) 1� - $ 00-t C'Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME D � C1�. l 1 I . . n A - P N # ExT' <br /> HOME Or MAILING ADDRESSl is 9. 9c/ oo I L)+ � l5 I ) <br /> CITY LOD ( `j n STATE 60 ZIP 15 o <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, STAT.16i­i FEDERAL laws. <br /> APPLLCANT'S SIGNATURE: i , DATE: (ar��_ �t1 dy <br /> PROPERTY t BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT/ 300I ,,'� <br /> If APPLJCANTisnotthe BlLLmrGPAR 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 environmentaUsite 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: RDAT <br /> COMMENTS: <br /> AUG 12 2020 <br /> SAN JOAQUIN c <br /> HEALTH DEAR'-ENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: S (�/I l/VI,{VQ EMPLOYEE DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: D(o( PIE: I 0 OZ <br /> Fee Amount: l52 .� Amount Pa �5,� b Payment Date $� Za <br /> Payment Type x.. Invoice# Check# I �b� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />