Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST'#7 <br /> 74?e C' Ot�2(� P SQ O `4�z5 <br /> OWNER/OPERATOR <br /> t ), CHECK If BILLING ADDRESS 11 <br /> /G/t� <br /> FACIU ry NAME <br /> Sa2eGw�- <br /> SITE ADDRESS / �� MI�� r L Yell 9j''-,° <br /> J treat Number Direction Street Name Clt J' 7 ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 'J e— Street Number Street Name <br /> CITY STATE ZIP <br /> J� <br /> PHONE#1 En' APN# [AND USE APPLICATION# <br /> I (�) 36V <br /> PHONE#2 KT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORESSO <br /> BUSINESS NAME /� - /J t PH E# E" . <br /> 'T� � .� Com' GL t'✓) t7 L <br /> HOME or MAILING ADDRESS FAX# <br /> I ) <br /> CITY STATE ZIP v <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: XS JM/ , 1,. S, _C Q' ,m ti DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT is not the BlLLlNG 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 environmentaVsite 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 the or my representative. 1,� PAYMENT <br /> TYPE OF SERVICE REQUESTED: '49A 0J m RECEIVED <br /> COMMENTS: <br /> JAN 11 2022 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEpARTW T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEEM DATE: L- <br /> Date Service Completed (if already completed): SERVICE CGDE: <br /> Fee Amount: J Amount Paid l5�2 Payment Date ZZ <br /> Payment TypeUInvoice# C # 3IsReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />