Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> �UC7rx� CHECK If BILLING AODRESSo <br /> FACILITY NAME �j / n�1 -t�� q <br /> SITE ADDRESS ' �`��� <br /> Street Number Direction 1 Street Name CH ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY -A„ -M _p ove- STATE ZIP <br /> PHONE#1 En. APN#1 �� �'•XLAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR <br /> Jan <br /> ,�n \ V0n CHECK If BILLING AoORESSEI <br /> BUSINESS NAME PHONE# En. <br /> v^' �� i�' S <br /> HOME Or MAILING ADORES 1'l.V `A%# ) <br /> CITY PC STATE ZIP <br /> BILLING ACKNOWLE MENT: 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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNEB'LJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> ifAPPLICANT Is not the BILLINGPARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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 die 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. DPq <br /> TYPE OF SERVICE REQUESTED: '`ecel <br /> COMMENTS: JULI „ 5 2022 <br /> �JJOAQUUIN COU <br /> NTY <br /> HEALTN D PAIRAONMlNTAL <br /> R MENT <br /> (ho of ow <br /> ACCEPTED BY: rol EMPLOYEE#: DATE: v✓ <br /> ASSIGNED TO: v'r l EMPLOYEE#: 111Z71 DATE: 2Z <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I : 02 <br /> Fee Amount: '0 o Amount Paid Payment Date -7� ZS Z Z <br /> Payment Type Invoice# Z (( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />