Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST �;,I I 1?0el rfs-3 '7r i 7 <br /> Type of Business or Property FACILITY ID# 575V42 <br /> EQUEST# <br /> P_�i t 9, Ti/f-e-- <br /> :L OWNER/OPE ATOR 0 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> IyD ,ssy��.. A4 G®o 9�zy� <br /> Street Number Direction treat Name CitV Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (241 ) '327 —Co/97 /33 - 3f <br /> PHONE#2 EXT. BOS DISTRICT / ) LOCATION Cq�E <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME /L .�Z-�d� PHONE# EXT. <br /> ?.07 '3 'Z 7 —CP/9 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY / n�� STATE (f ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned roperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRO EN AL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as ident' LthisI also certify that I have prepared this application an thperformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F D <br /> APPLICANT'S SIGNATURE: DATE: <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 <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: D <br /> COMMENTS: 1/e r; (y Curl YI eL fl J Y) 6it P:JOI }Q S: P fI4. ;y5trYYl. <br /> SEP 17 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C�j�� EMPLOYEE#: DATE: �7ao;0 <br /> ASSIGNED TO: D4 EMPLOYEE#: DATE: dP� <br /> Date Service Completed (if already completed): (ZCj 2-A) I <br /> SERVICE CODE: Q PI E: q,) <br /> Fee Amount: 15 Amount Paid / S — Payment Date <br /> Payment Type ;:- ;_ Invoice# C heck# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />