Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7c. 563 <br /> OWNER/OPERATOR <br /> ] <br /> L 7 CHECK if BILLING ADDRESS LC <br /> FACILITY NAME <br /> A -�' l 't'{^ " <br /> SITE ADDRESS IV (j c,'/.—) Q <br /> Street Number Direction Street Name C ity 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. API# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 4�- CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex,. <br /> HOME or MAILING ADDRESS FAX# <br /> (999 o 1A l) (CA. <br /> CITYI ,� ST T,E- ZIP t'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,STAT ERAL laws. <br /> APPLICANT'S SIGNATURE: �� DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER EV 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 <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. WMENT <br /> TYPE OF SERVICE REQUESTED: a*? b (/1 Q/r SRECEIVED <br /> COMMENTS: <br /> JAN 2 6 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1023 <br /> ASSIGNED TO: 1 EMPLOYEE#: / �j S DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0b I <br /> P/E: I p Z <br /> Fee Amount: , �J 0 U Amount Paid 1s--7, Payment Date ( Z(��� 2— <br /> Payment <br /> Payment Type V'1 Invoice# C4etrk# !5� 1 Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />