Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING AOORESS ff <br />BUSINESS NAME <br />FACILITY ID # <br />PHONE#) <br />SERVICE REQUEST# <br />� It 7�Y1 Q <br />DATE: (!` ZZ <br />- <br />HOME <br />or MAILING (ADDRESS <br />DATE: y <br />OWNER/OPERATOR <br />SERVICE CODE: <br />LtJ '0 <br />P E: <br />( ) <br />_. <br />ri L`/' ILl/.LWT I /T <br />CITY <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />-W <br />Payment Type C C <br />- <br />71 lq Z3 i'4 <br />'7 <br />Received By: <br />{ I <br />111 <br />SITE ADDRESS <br />I��mmer°bwn <br />IDnve <br /><Nx. tonlcA <br />0I5a10 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street <br />Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#t <br />EZT• <br />APN # <br />LAND USE APPLICATION # <br />( ?Vq Si <br />PHONE#2 <br />En. <br />BOS DISTRICT <br />LOCATION CODE <br />(SID) 381 Le L11 L� <br />CONTRACTOR / SERVICE REQUESTOR , <br />REQUESTOR iQ K l� 'V`t� fl ^,u 1 '_ <br />�/t <br />CHECK If BILLING AOORESS ff <br />BUSINESS NAME <br />) 1 I <br />PHONE#) <br />EXT. <br />_ <br />� It 7�Y1 Q <br />DATE: (!` ZZ <br />- <br />HOME <br />or MAILING (ADDRESS <br />DATE: y <br />FAX# <br />SERVICE CODE: <br />LtJ '0 <br />P E: <br />( ) <br />Fee Amount: <br />CITY <br />STATE C4 <br />ZIP I SO I <br />BILLING 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 <br />COUNTY Ordinance Codes, Star(d <br />APPLICANT'S SIGNATURI�` <br />PROPERTY / BUSINESS OWNERI� <br />If APPLICANT IS not <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />FEDERAL laws. <br />AA _ DATE: 4I0 I, -'p <br />MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />BILLINGPARTY 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 the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVD2oNMENTAL HEALTH DEPARTMENT as Soon as It is aygi),gbluanENTe same time it is <br />provided to the or my representative. FF''//�{�Y M� <br />TYPE OF SERVICE REQUESTED: <br />KEUMVED <br />COMMENTS: <br />APR 19 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: Zi3 <br />DATE: (!` ZZ <br />ASSIGNED TO: <br />EMPLOYEE#: �� <br />DATE: y <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />J % 7 <br />P E: <br />Fee Amount: <br />Amount Paid <br />�-/ <br />Payment <br />Date // /Z <br />Payment Type C C <br />Invoice # Gheh <br />71 lq Z3 i'4 <br />'7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />