Laserfiche WebLink
Q�2U Sato l��e Z <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# S RVICE REQUEST# <br /> E — -33T - <br /> OWNER/OPERATOR_ <br /> / Cruse <br /> CHECK If MILLING ADDRESS <br /> FACILITY NAME VA«eL Erle <br /> SITE ADDRESS l ri <br /> +N <br /> Street Number Direct+an Street Name _l Zi Code <br /> HOME Or MAILING ADDRESS (ff Different from[Site,,AddresS) <br /> Or4 an j� cL (Street Number Vr `Street Name <br /> CITY 1- STATE LP <br /> tX1 ` ✓ b <br /> PHONE#t fir' APN# LAND USE APPLICATION# <br /> ( ) zwo — Q <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BIWNG ADDRESS <br /> BUSINESS NAME PHONE# EV' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: L 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 he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � C DATE: <br /> PROPERTY/BUSINESS OWNERIM OPERATOR/MANAGER ❑ OTHER AUTHORuF,D AGENT❑ <br /> If APPLICANT is not the B&MNGPAR7Y.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. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> sqN MAR 10,10 2021 <br /> hFgLTN p&O4QljAN7ATA1NTy <br /> ACCEPTED BY: �µ-ff�LSL� EMPLOYEE#: DATE: GI, —IO <br /> ASSIGNED TO: a� EMPLOYEE#: DATE: �7✓✓�rO <br /> -24 <br /> Date Service Completed (ii Almady completed): SERVICE CODE: L9 to/ PIE: /6C)2_ <br /> Fee Amount: /.S Z . Amount Pal �� Payment Date 3 ro <br /> Payment Type ��1 Invoice# Check# 121 �Y Received By: s <br />