WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business ar Property CHECK NBILLING ADDRESS FACILITY ID # SERVICE REQUEST # r00.D TRUck . HOME or MAILING ADDRESS B L13 4312 G1 Z OWNER r OPERATORjn R Fr� Ht—Fl l) P� CHECK H BILLING ADDRESS p FACILITY NAME cu R<;Y 6X p F CS -S SUE ADDRESS I I D� DATE: Street Number Direction Street Name cityZi Code HOME or MAILING ADDRESS in Different from Site Address)�gparQ Amount Paid , UD iau3 Street Number eet Name a`TM Mall y STATE g533i PHONE #1 Ezr. APN # LAND USE APPLICATION # (409) 5ro- 8251 ( 03 E% lot) 5ov Ii T BQSDISTRICT LOOCOOE CONTRACTOR / SERVICE REQUESTOR REQUESTOR L� Ttrn� F.t1tLi CHECK NBILLING ADDRESS BUSINESS NAME v C D PHONE# Eu. If 4b8 Sze i?257 HOME or MAILING ADDRESS B L13 FAX # 111 1 CRY /vlart-kea STATE CA 7rP 95331 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andlor project specific ENVIRoNNT.NTAI. IIEALTH DEPARTMI-an' 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 JOAQu[N CouNTY Ordinance Codes, Standards, STATE and FEDHRAt. laws. APPLICANT'S SIGNATURE: � C� " DATE: D% In J 3G27t PROPERTY/ BUSINESS OWNER0 OPERATOR/MANAGER ❑ 0,ruca ATrrucaTZED AGENT 13 1fAPPL1caaT is not the B/LLEm 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 ENviRoNNiENTAi. 11E.4i.nl DEPARTMENT as soon as it is available andret�j}If_'�•a^me time it is provided to me or my representative. ni'/.�{_1'/ t 1 E'/U T TYPE OF SERVICE REQUESTED: v C D COMMENTS: & - //O N 1, %0 JUL 2 9 2020 SAN JOAQuINALTHDCOUNTY ENTAL HEeE ACCEPTED BY: �- EMPLOYEE#: IA J DATE: ASSIGNED TO: EMPLOYEE#: D� DATE: Date Service Co ete IIT alreadj completed): SERVICECODE: 2 Z. I PrE: p Fee Amount: Amount Paid , UD Payment Date 7 Z Payment Type Invoice# Check# JJQ S S I Recei dBy: EHD 48-02-025 --- Owpe� ` •Jay SR FORM (Golden Rod) S