Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA mW121(0l 2 j Rmm 8-4'A S 3 <br /> OWNER/OPERATOR & <br /> ��t CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ,I/ N ��1 <br /> SITE ADDRESS 1 O,00 70, <br /> Street Number Direction ` ` (Street Name Crit "Z✓i Codel <br /> HOME or MAILING ADDRESS (If Different from Site Address) I�2 Si�`h17 <br /> Street Number Streee <br /> CITY /� ,� Ilk <br /> STATE <br /> C t _ ZIP <br /> PHONE#1 /� EXT. APN# LAND USE APPLICATION# `L�1�✓ <br /> (2M) 321 — <br /> PHONE#2 Eur. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR/ 1 /)„�� CHECK if BILLING ADDRESS <br /> BUSINESS NAM\EJ�`/J,n ��JV �1L _�(� PW 32`j Ems• <br /> HOME or MAILING ADDRESS J' `1 �lC/Y� rn, /v FAX# <br /> ( ) <br /> CITY aft-y STATE ZIP G���.j 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, Stan rds, STATE a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: l 115 r��-3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATI ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is n t t e BILLING PA TY, 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. r Ap <br /> TYPE OF SERVICE REQUESTED: C;r c 1 e- Ui O W nE? s I <br /> COMMENTS: <br /> Ai0 <br /> tY v <br /> .31% qQ ,5 ?023 <br /> N��yiD Sq'V �Vn' <br /> ``,A�4 T�,fFMT <br /> ACCEPTED BY: 'a6ovAne 1EMPLOYEE#: DATE: <br /> ASSIGNED TO: UI d�1 EMPLOYEE#: DATE: ,11t5`2cZ`23 <br /> Date Service Completed (if already completed): SERVICE CODE: Qi(_,I P/E: k(,(p 2 <br /> Fee Amount: I(CZ (Lop Amount Paid do Payment Date 11115-12-3 <br /> Payment Type ( Invoice# Check# J �Zl R ceiv d By: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) I <br /> 03/22/23 <br />