Laserfiche WebLink
r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (jo e S�0 � P-008(02-9 + <br /> OWNER/OPERATOR rn� pp <br /> L;s be4 k ` \ e r CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ttc, Lod'i 95 2 y 2 <br /> 'Street Number Direction -f' Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 23S <br /> PHONE#2 EXT_ BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / is f Q r CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME /\ nh PHONE# ExT' <br /> ��,eC r' ovVL 9 S S - T7 <br /> HOME or MAILING ADDRESSFAX# <br /> Ngo w . 14 le mL�#� ( ) <br /> CITY Lod,p r STATE eA ZIP '76 2 LL <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 an F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ill, . 2 3 23 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13If APPLICA T 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 <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. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JAN <br /> qp' 2 3 2023 <br /> ORONMENTAL <br /> DEPARTMENT <br /> ACCEPTED BY: h /p to/ 6Q <br /> EMPLOYEE#: I DATE: 112--31-Z3 <br /> ASSIGNEDTO: 4 UV c��� a(� U� Z EMPLOYEE 14( i.j DATE: Z3 23 <br /> Date Service Completed (if already completed): SERVICE CODE: 0101 1 P 1 E: �L <br /> Fee Amount: ` Amount Paid Payment Date l a 3 0-Lo a3 <br /> Payment Type Invoice# C # 5Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />