Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2-�Wim/ ="Q 009(O-T-�;-Z <br /> OWNER/OPERATOR T^� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME I J O I /� / 0 r ' <br /> SITE ADDRESS I v �,5c�,c no" o ST C�1 �5 c� X10 <br /> 3 C` ST Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> SSD ) 1 6tS <br /> PHONE#2 ExT. EMAIL BOS DISTRICT-F LOCATION CODE <br /> © ) I�31 — <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEI ,� /VI <br /> ^/ - n/ /A C ©0WTI � r C PHONE# EXT. <br /> HOME or MAILING ADDRESS 'V l V��-7 /1 � FAX# <br /> CITY ��� TATE C A ZIP .� rI EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: Sii DATE: o� <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: NkO h�t lle— EFuot;.1! <br /> RECEIVED- <br /> COMMENTS: �.y _ F dw�'�C.✓S p <br /> MAY 2 4 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY'ar �S � EMPLOYEE#: C tE(' DATE: <br /> ASSIGNED TO: 1 )c,-r kc, EMPLOYEE#: q 5 215 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1151. <br /> %(0m Z <br /> Fee Amount: j'5(, Amount Paid / Payment Date <br /> Payment Type S Invoice# # f Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />