Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 131iio <br /> OWNER/OPERATOR <br /> ,rte CHECK If BILLING ADDRESS <br /> FACILITY NAME ' f r <br /> r V ftt K1fck+a <br /> SITE ADDRESS S <br /> '1 Street Number Direction G 1 Ve Street Name LC,��` city �ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 4 he h V Street Name <br /> CITY STATE ZIP <br /> 4 a <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (z•y 1 'AC3 8�t 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> t <br /> BUSINESS NAME PWNEq# EXT' <br /> ft' "Ag Swt Cafe h .fir X63-f�.216 <br /> HOME or MAILING ADDRESS FAx# <br /> '315 4h6ch Apence I <br /> CITYeo 4' SC_ 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 FFE+DERA laws. G 7 <br /> APPLICANT'S SIGNATURE: a& Cf'1 DATE: 0 0-6 T—d O.�o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER P1OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PAR TP prop 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 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: <br /> COMMENTS: <br /> sAIv'l 0 2 2020 <br /> FN OAQUi <br /> Hr,4L-rH OFPMR wUNT y <br /> ACCEPTED BY: , M EMPLOYEE#: DATE: <br /> ASSIGNED TO: J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: ' Z <br /> Fee Amount: `°g Z_ Amount Paid ! Payment Datei7 0 <br /> Payment Type Invoice# Ghe—on L'z gGj� Receive Bye 1� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />