Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -,Y 1 W ovgw?� <br /> OWNER I OPERATOR ^ <br /> Sao to o /� V \ I �� CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME M��� / v <br /> QITF ADiler^^ I )1 �7 C�.e C 0 1 i�l L-��(�I 1 r qS`2 <br /> �L F <br /> Street Numher Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY �� �-T <br /> ATE IP <br /> 14 <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (IM) q 03 - 31'1-1 <br /> PHONE#Z E-. EMAIL BOS DISTRICT LOCATION CODE <br /> c �=73(a L4 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , A o 11 <br /> t I r CHECK If BILLING ADDRESS <br /> BUSINESS NAME , �^ 1/ r j PHO O 1 Fy, <br /> HOM or MAILING ADp ESS , Y FAX# ) t <br /> CITY WSTtfq ZIP n� I EMAI � j/G /�y <br /> `�' f 1.1 ry)--,A <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sa , <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: C � ZfZZ Ur <br /> 7gg24-0 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �f <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 provl�tj1e or my <br /> representative. �1 ``/A•.�N,,Y <br /> TYPE OF SERVICE REQUESTED: �'UQ C vV 1S l �G�J' V _ '� l�� <br /> COMMENTS: z <br /> a"JO �, 1023 <br /> HtACTy 0Ep M��qY <br /> - T <br /> ACCEPTED BY: y � EMPLOYEE#: DATE: y 12D 'Z <br /> ASSIGNED TO: 9a EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(.01 P I E: 1002 <br /> Fee Amount: c ,1S _ Amount Pai /S(��� Payment Date <br /> Payment Type 1 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />