Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA ()0320 2 o qq <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �0� �lU �vG S OG'c��011 yrjp�O� <br /> (/ Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if\Different from Site Address) <br /> l/ T Street Number Street Name <br /> CITY STATE ZIP <br /> Cx <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> G � .ten C"- <br /> BUSINESS NAME PHONE# EXT. <br /> 1 o, o <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <br /> - � G <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: `�)0 \g Co Le-)cz- DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/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: Ct PAYMENT <br /> COMMENTS: RECEIVED <br /> JUN 2 9 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: t/l f t EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: r v\/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: [P/E: 0 2 <br /> Fee Amount: CJ(0— Amount Paid 1 Payment Date Z <br /> Invoice# C ck# Q Received By: <br /> Payment Type l S/T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />