Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ='S <br /> ERVICE REQUEST# <br /> 00i'f5DD <br /> OWNER I OPERATOR <br /> 11,`J , � CHECK if BILLING ADDRESS <br /> FACIIL� <br /> �NAME n �[ <br /> SITE A� <br /> ()DDRc,� I , I e C( I�'� 0{1'1 I G <br /> V Street Number L) n I Street Neme CI Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) V G <br /> C /j <br /> Street Number Street Name <br /> CITY ! � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2()Cj Ll Flt "PS75 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I \ .L <br /> L—' F �/ LC CHECK if BILLING ADDRESS <br /> BUSINESS NAME u ` Z z j 5 <br /> < <br /> HOME or MAILING ADDRESS - n FAx# <br /> 6,7 In 4 <br /> v Yt { ( ) <br /> CITY 'S <br /> 1 QC I^ 11 STATE 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 Wthad, to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and <br /> APPLICANT'S SIGNATURE: RATE: �� 2 <br /> PROPERTY/BUSINESS OWNER❑ OP / ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL GPARTY 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 rTj iilCi9a kir it is <br /> provided to me or my representative. E E <br /> TYPE OF SERVICE REQUESTED: V eki ch � +� <br /> COMMENTS: tn� <br /> I 6 � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Ci1 'a-L mgr�D 5-7 D 3 (2 HEALTH DEPARTMENT <br /> . <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1-15-21 <br /> —I 2 I <br /> ASSIGNED TO: jb EMPLOYEE#: O',�'3 DATE: 1 .J <br /> Date Service Completed (if already completed): SERVICE CODE: --r 11 PIE: I w) <br /> Fee Amount: _ Amount Paid Payment Date b <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />