Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::1_ �--A W2-19S3 S,Q leo <br /> OWNER./OPER TORT <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME, <br /> SITE ADDRESS f nr•D rt F� Q <br /> Street Number Direction treet Name �' •'/ Cit Zi Code <br /> �HMO E Of MAILING ADDRESS (If Different from Site Address) U0460, UOt''I <br /> 1`114 Qg6dgjq,� Street Number 1 Slreet Name <br /> ' 5V r I STATE ZIP <br /> PHONE#t-1 ErA- S. <br /> ST APN# LAND USE APPLICATION <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR. <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME pHONE# EXT, <br /> `HOME Or-MAILING ADD ES FAx# <br /> ( ) <br /> GI MQn C— <br /> STATE ZIP 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 applic '9I and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S TE an FEDERAL laws. <br /> APPLICANT-'S-SIGNATURE: DD TgT-V 19 A 1��L, <br /> PROPERTY/BUSINESS OWNERILI OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT//is not ee BIL G 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. ®®�q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �,g� ��® <br /> e�_ O 4- � � jut 18 <br /> s'f',,ogQUtN 2021 <br /> H ROryM NOUN <br /> I <br /> TNOBP�TAL Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q1 /t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P/E: Ito <br /> Fee Amount: r� Amount Paid 52 Payment Date 2CJ <br /> Payment Type Invoice# Cbec ' r 129 I( 3-4Received By:: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> PR�53�88� <br />