Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4 4R/CULTLIgAL <br />FACILITY ID # SERVICE REQUEST # <br />S‘Z WgLI -1-1 <br />OWNER/OPERATOR CHECK if DAAI R. cWsrA-, hve. DANN co5r,4 BILLING ADDRESS rill <br />FACILITY NAME <br />SITE ADDRESS / 7„t3 I <br />Street Number <br />..,e-: <br />Direction <br />.2__er/SE /QC' • <br />Street Name <br />--5.CALo/k/ <br />City <br />95-3.2o <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. SOS DISTRICT Li LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />DOA( GPF5iViy F' CHECK if BILL ING ADDRESS <br />1 BUSINESS NAME _ <br />1-1 6 /4 Ey coNsce -/p/ <br />PHONE # 1 Ex-r. <br />HOME or MAILING ADDRESS <br />p• O • 5.0/ 3714- <br />FAX # <br />( ) <br />CITY ,----- <br />f a e-/-0 CIL <br />STATE CA ZIP 94 5-3yil <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 />COUNTY Ordinance Codes, Standards, <br />I also certify that I have prepared this ap.: . • ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />EandFEP laws. <br />/ <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br />If APPLICANT is not the BILLING PARTY, proof of a thorization to sign is required <br /> 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 aniliMpliolirne it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 6 5 /J,_ Rgi4 E v,/ <br />111L'irrinoll V imam/ <br />COMMENTS: JAN 26 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: .--'""-- 7z L. L_ EMPLOYEE #: DATE: Va 0 , <br />ASSIGNED TO: A (--, EMPLOYEE #: DATE: ib 0 / <br />Date Service Completed (if already completed): SERVICE CODE: (.1c c.) ',... PIE: <br />Fee Amount: i co g Amount Paid "it Payment Date t/7,_ 72,0 j_-L. <br />Payment Type _jtc.._ Invoice # Check # <br />-3-r <br />Received By: A191. <br /> DATE:/ <br />OPERATOR MANAGER 0 OTHER AUTHORIZED AGENT PZI <br />/4G72,6,aa <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003