SR0085039 - Laserfiche WebLink

Home Browse Search

f ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 1/1: 14 FACILITY ID # BUSINESS NAME SERVICE REQUES PHONE# EXT. RECEIVED FOR INSPECTION. J�00� 7(Z— 1<1U HOME or MAILING AD RSS / ACCEPTED BY: L L-- FAX # DATE: 3t I a OWNER/ OPERATOR EMPLOYEE #: DATE: 31; 1'12 a Date Service Completed (if already completed): CITY ^ CHECK if BILLING ADDRESS FACILITY NAME / Fee Amount: a SITE ADDRESSj�%/�% ' s 2—I Z� 3 Z V Payment TypeItS 3 Street Number Direction 0 ` � '/ tCK e HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PCs?) 7/2—t(k( PHONE#2 EXT. ( ) BOSDISTRICTf 1 `-11 CATION CODE T CONTRACTOR / SERVICE REQUESTOR REQUESTOR / C 1/1: 14 CHECK If BILLING ADDRESS BUSINESS NAME �0 $70 PAYM NT.C� PHONE# EXT. RECEIVED FOR INSPECTION. A 7(Z— 1<1U HOME or MAILING AD RSS / ACCEPTED BY: L L-- FAX # DATE: 3t I a ASSIGNED TO: �1 /'_ EMPLOYEE #: DATE: 31; 1'12 a Date Service Completed (if already completed): CITY ^ STATE / �F ZIP / Fee Amount: a Amount Paid BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER [a OPE OR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Ve f i d Coa n e ec t o n 1/1: 14 COMMENTS: `aCoe- F a) �0 $70 PAYM NT.C� CALL (209) 953-7697 RECEIVED FOR INSPECTION. MAR 2 1 2022 24-HOUR NOTICE REQUIRED. ACCEPTED BY: L L-- EMPLOYEE #ENVIRONMENTAL DATE: 3t I a ASSIGNED TO: �1 /'_ EMPLOYEE #: DATE: 31; 1'12 a Date Service Completed (if already completed): SERVICE CODE: Oct PIE: 9d O a Fee Amount: a Amount Paid ' s 2—I Payment Date 3 Z V Payment TypeItS Invoice # Check # Received By: EHD 48-02-025 I ` O " 3 " O SR FORM (Golden Rod) REVISED 11/17/2003