SR0083212_SSNL - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRi BUSINESS NAME n/a FACILITYID # SERVICE REQUEST # Residential �'� }l1 pyJY1Bi j Oen�ret6hr/Sefvl SeN<JIP r•o bo FAX # APN 17302010 ( ) (� �' Oki OWNER/ OPERATOR II �oilct•fVll m p'105 Lo' 'er II koG�trx;vee CHECK If BILLING ADDRESS❑ ACCEPTED BY: EMPLOYEE #: DATE: FACILITY NAME EMPLOYEE M DATE:��C(� a Valdovinos Residence Date Service Completed (If already completed): SITE ADDRESS 2387 P E: d 6q, Learned Avenue Amount Pal Q D Payment Date % 2S2 Stockton Invoice # 95205 Street Number Direction Receiv d By: Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 13 y ��brook e Ail n �eYc& Ave Street Number Street Name CITY f/ *ial S�J N STATE CA ZIP ns S eCB� F PHONE #1 EXT. APN # LAND USE APPLICATION # (209) 628-0986 173-020-10 PS -2002678 PHONE #2 EXT, BOS DISTRICT LOCATION CODE ( ) I CONTRACTOR /SERVICE REQUESTOR REQUESTOR Jose valdovinos, Owner CHECK If BILLING ADDRi BUSINESS NAME n/a PHONE# EXT. COMMENTS: RSC FV $(1' V 4eA eW (T I j, 1� 209 628-0986 HOME Or MAILING ADDRESS �'� }l1 pyJY1Bi j Oen�ret6hr/Sefvl SeN<JIP r•o bo FAX # 733 Shadowbrook Lane ( ) CITY Manteca STATE CA ZIP 95336 BHILING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project SpeCifiC ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: � DATE: 1/26/21 PROPERTY / BUstNESS OWNER1pw1&k PERAT / MANAGER ❑ OTHER AUTHORIZED AGENT.I If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYeda_ ll r TYPE OF SERVICE REQUESTED: Sa; JUii'Gt�l 117 ,x,v( j fU, j'l��c L�n' Sfiu� %levfpy/ COMMENTS: RSC FV $(1' V 4eA eW (T I j, 1� .IAN �'� }l1 pyJY1Bi j Oen�ret6hr/Sefvl SeN<JIP r•o bo ee'. YetuPs]Or, X20 l wtv COUP R� EACtyCEp MR ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE:��C(� a Date Service Completed (If already completed): SERVICE CODE: P E: d 6q, Fee Amount: tv �Q Amount Pal Q D Payment Date % 2S2 Payment Type Invoice # Check # Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 ti