Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />—�,O /cJGE$fra*•IS rJ /IJ <br />FACILITY ID # SERVICE REQUEST # <br />SC o-UL� <br />S2V17`aZO�Z <br />OWNER / OPERATOR <br />ACCEPTED BY: Vidal Pedraza <br />CHECK It BILLING ADDRESS <br />FACILITY NAME <br />!/IrtAD&ea,*1rdAyF( <br />0, C�i•N7.0Ay 9(-Vd • <br />/�dD I <br />gSz�O <br />Street Number Dirft4i <br />4-21-20 <br />Date Service Completed (if already completed): <br />>7 <br />HOME or MAILING ADDRESS (N Different from <br />Sitedd <br />Aress) <br />�� s.r <br />Fee Amount: 406 <br />CS StrW Number <br />'e, Stre I Nerne <br />CITY ( <br />STATE G zip <br />PHONE#1 E• <br />`T6z,4r <br />Payment Type J 5�_ <br />APN#LAND <br />USE APPLICATION# <br />PAYM <br />() q _ <br />Ree ved By: <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />11 <br />LOCATION <br />ADA <br />CONTRACTOR / SERVICE <br />REQUESTOR <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />13 0 3 <br />CITY I <br />PHONE# <br />FAX# <br />SAN _vGV <br />4LI <br />CHECK D i AQUI (JN' <br />L <br />^ Ezr. Ery <br />STATE n w 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 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: �fJZI /Zo <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTRERAUTHORIZED AGENT® ag.`JA,8aU CDr111td•L7L✓i/VP <br />If AaruotNT'isnottheBiLLayCPAR proof of authorization to sign is required Tilt* <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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN r 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: £6T (/(�W <br />—�,O /cJGE$fra*•IS rJ /IJ <br />i.✓� <br />COMMENTS; <br />ACCEPTED BY: Vidal Pedraza <br />EMPLOYEE#: 621.3 <br />DATE: <br />4-21-20 <br />ASSIGNEDTo: Stephanie Ramirez <br />EMPLOYEE#: 1084 <br />DATE: <br />4-21-20 <br />Date Service Completed (if already completed): <br />I SERVICE CODE; <br />523 <br />P 1 E: 1601 <br />Fee Amount: 406 <br />Amount Pa <br />��, v� <br />Payment Date <br />iLlZ <br />Payment Type J 5�_ <br />Invoice # <br />Check # 1077E/'?,SE <br />Ree ved By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11(17r2003 <br />