Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA s <br /> OWNER/OPERATOR n <br /> l _ y` In (` f ��Q/I(`Q �H fX if BILLING ADDRESS <br /> FACILITY NAME � ` /�e�ms- <br /> SITE <br /> ^ I `P`1-� ` I I t- .J P-�`' <br /> SITE ADDRESS 6gSo) -?4�l Ci G I_ _„ 5�, 1 (�'S 7-LT4 <br /> Street Number Direction -}_t Street Name TV YJ ' Y�C'ft`' ZipCode <br /> "7 <br /> HOME or MAILING ADDRESS (if <br /> ppDifferent fromSiteAddress) <br /> 0 7 si qq/v 6 (f L f(lEC� Street Number Street Name <br /> CITY'57 <br /> STATE ZIP <br /> PHONE#1 / Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST04 <br /> CHECK If BILLING ADDRESS <br /> / . GC <br /> BUSIN N MEPHONE EzT. <br /> L ��P2t ��. ) Yrib-6 Zo <br /> HOME or MAIL RE it _� � FAX# <br /> U 7 ,m/Cl GV�.0 ( , <br /> CITY G � STATE /�s^ IP <br /> BILLIN✓G 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 Coder,Standards, S n L laws. <br /> APPLICANT'S SIGNATURE: DATE: / J ➢�z Z <br /> PROPERTY/BUSINESS OW. RATOR ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ 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 die 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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: , <br /> COMMENTS: <br /> G/l�l t/l Q` f1 d I/�VIL (2SLtt�Q SAN FEES 18 2022 <br /> U/N <br /> NBALTy PgREnNOt I1' <br /> ACCEPTED BY: EMPLOYEE#: DATE: I—3I�2 1— <br /> ASSIGNED <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 02 <br /> Fee Amount: 4is Zz— Amount Pal 1S2,06 Payment Date <br /> Payment Type Invoice# Check# 1367`(,2 ?Y3 Receive By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 fn CJ50-7D <br />