Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#11 SERVICE REQUEST# <br /> (( <br /> VCE�0)) <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADORES <br /> Q Yvef 'ITYIVLST1rncfTS <br /> FACILITY NAME CcmeS '5'5D UtO c � om ) <br /> q�Si'n <br /> SITE ADDRESS / 1 <br /> ySDtmetNumber imcton PeetFt, RStmetNme SFDGI(}ah gSZO� <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1%40 51, Mt gvck or 4v116 ZOfo <br /> „r__-, Street Number Street Name <br /> CITY STATE C LP <br /> a145g6 <br /> PHONE#I En. APN# LAND USE APPLICATION(810 ) �4-14TS <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> 775 CHECK I(BILLING ADDRFSSff <br /> BUSINESS NAMEPHONE# En. <br /> 9tt 1`- ?\kLe, 1 51-3 - 2483 )o3D <br /> HOME or MAILING ADDRESS 13400 IL,j usicke QrSV , Sv�l'G Z"OZ Fft#' F"'"�I'`TS®QcTMII-PIACC c Yrs <br /> Cm S�c1 n AkS STATE a zip r�l'123 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that 1 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 w5. <br /> APPLICANT'S SIGNATURE: vy//^'� '%�Y'.' DATE: 12/18/2020 <br /> 11 ^^ 'T''��1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT N'� _ GV 1TW <br /> 1JAPPL/CANT IS not the BILLING PARTY proof of authorization to sign is required rifle <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 environmet '�yy/IyS�se_ssment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available andV}lie Sdr�/yUt,. is <br /> provided to me or my representative. • ,c C 11'- 71 <br /> TYPE OF SERVICE REQUESTED: WV J <br /> COMMENTS: SAN JD 2021 <br /> Q�u(As (In �PJ be'lve yFq�rHo�NMFN UNry <br /> C Penni+ PtoCO— r cc,-n`�'me_lendez is Pmd er ci/V7'P4R4Nr <br /> robe' "holy 1( <br /> ACCEPTED BY: EMPLOYEE III: DATE: <br /> ASSIGNED TO: EMPLOYEE 0: DATE: <br /> Date Servicempleted (if already completed): SERnCECM: PIE: D <br /> Fee Amount: Amount Paw 7 e(ZD Payment Date Z <br /> Payment Type Invoice# Cheek#S60I q2ln7o I'Ree Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />