Laserfiche WebLink
R "b-, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# ExT. <br />SERVICE REQUEST # <br />I <br />CITY C `^, STATE C ZIP <br />EMPLOYEE M <br />SRmOg5HO0 <br />OWNER/ OPERAT OR <br />EMPLOYEE #: <br />DATE: 9 <br />CHECK if BILLING ADDRESS <br />FACILrrY NAME <br />SERVICE CODE: a 3 <br />SITE ADDRESS O <br />P 1 E: <br />E, <br />Amount Paid <br />�2c� -- Payment Date <br />CJ <br />Street Number <br />Dlredion <br />Street Name <br />1Received By:�j <br />city__1 <br />ZiP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1 -S' 0 Street Number <br />Street Name <br />CITY <br />L � C ��_ o � <br />STAC--A ZIP G\ --s J <br />PHONE #1 ExT• <br />(��al 2s,- ,D(0 ��0 <br />APN # <br />0 -?a -)03a <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />( ) <br />BOS DISTRICT <br />�L� <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR I <br />REQUESTOR <br />1 Z v, CHECK if BILLING ADDRESS <br />\! �l <br />BUSINESS NAME \ <br />PHONE# ExT. <br />HOME Or MAILING ADDRESS <br />� t J -�1 � ►vim �, `� <br />FAX# <br />c ) <br />CITY C `^, STATE C ZIP <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 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. Q� <br />APPLICANT'S SIGNATURE: -��C DATE: <br />PROPERTY/ BUSINESS OWNERP OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY. proof of authorization to siaQn is required Tirte <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 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: 15-,,-,J SU : 1 C9L,Jdy qh c' <br />I C, <br />COMMENTS: <br />T <br />REc��V�D <br />BSEP 2 0 2022 <br />H E�iR0kM COUNTy <br />ACCEPTED BY: <br />L✓ <br />EMPLOYEE M <br />DATE:C� p Maul, <br />y■ <br />ASSIGNED TO: R <br />EMPLOYEE #: <br />DATE: 9 <br />Date Service Completed (if already completed): <br />SERVICE CODE: a 3 <br />P 1 E: <br />Fee Amount: %a 1 <br />Amount Paid <br />�2c� -- Payment Date <br />1�--?' 2-,CDl 2- <br />Payment <br />Payment Type 0/h 2LP <br />Invoice # <br />Check # 1/291 <br />1Received By:�j <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />