Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S►2 �D8�l- PCO <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2 C-C�{ l'• /7 �' ^'�G`(�� ( 2 v C\"' <br /> Street Number Oiractlon Street Name Cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> GJ ki �� Street Number Street Name <br /> CIN \ STASE RS ao lo <br /> `j L-O C '� T'L IA <br /> PHANE , ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� p Com- PHONE# <br /> HOME or MAILING ADDRESS FAx# <br /> CITY \ STAT ZIPis <br /> O f. <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. <br /> APPLICANT'S SIGNATURE:�Y L k Z E \ C to- S \A\---< ay J DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is riot the BILLING PAR Tt' 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 1FDO RECEIVED <br /> COMMENTS: AUG 0 2 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ic EMPLOYEE#: DATE: 'L <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount• IG5v— Amount Paid S6 Payment Date <br /> Payment Type G a Invoice# Check# Received By: <br /> EHD 48-02 025 SR RM(Golden Rod) <br /> REVISED 11/17/2003 <br /> fao't8W3 <br />