Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> tv <br /> �g3 S IN <br /> OWNER/ OPERATOR 'RULJ <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> ,LRE (17Y 166 <br /> SITE ADDRESS qsoaci 'Ic. Ye S1Gck Vest. <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> O Street Number Street Nae <br /> CRY STATE ZIP <br /> k a <br /> PHONE#1 Ems. APN# LAND USE APPLICATION# <br /> (a(sR ) S <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> V 2,1 kf C <br /> HOME or MAILING ADDRESS FAX# <br /> i . ( ) <br /> CITY STAJE 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 aA that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and ERAL laws. <br /> PPLICANT'SSIGNATURE: DATE: , a 1 /doa1 <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. pPAYMENT R <br /> TYPE OF SERVICE REQUESTED: ECEI II GD <br /> COMMENTS: DEC 15 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> C 1 6 ,� p r sh IT HEALTH DEPARTM INT <br /> ACCEPTED BY: /a `(rl l� S .Jd l�-A -� EMPLOYEE#: DATE: v' <br /> ASSIGNED TO: ( EMPLOYEE#: I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P I E: <br /> Fee Amount: 5 Amount Paid I ,c"'2 -- Payment Date 2 r 5 z <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 SR f ORM(Golden Rod) <br /> REVISED II/17/2003 ��V ��^� �Z7 <br />