Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C nS ISP'ers(0621 <br /> OWNER/OPERAT <br /> � I CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME C. Q <br /> SITE ADDRE <br /> l� Street Number I Direction (� C v 1 Street Name 1 city I" Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY \ SZIP <br /> � 1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZLTo 5 //335y/0 <br /> PHONE#2 Err. EMAIL BOS DISTRICT LOCATION CODE <br /> 621y() Jr �) �— " 002- 449-4_ 01 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> v CHECK If BILLING ADDRESS <br /> BUSINESS NAME l_ PHO # EXT. <br /> COWHOMEOAILI G DDRESS FAX# <br /> lY S ( ) <br /> CITY STATE C ft . zip Gf 1 EM I �� 2 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, oVerator 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 /> 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 and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: -� f V11-eJ DATE: b — �-2.3 <br /> PROPERTY/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 pro me rile or my <br /> representative. nn �+ Y <br /> TYPE OF SERVICE REQUESTED: FC30< , <br /> COMMENTS: JUN 09 <br /> ,,o 2023 <br /> H FARO UI N CQU <br /> OF,2 At <br /> M NT <br /> ACCEPTED BY:'GL,c\CL"ne- EMPLOYEE#:0(f3(p5 DATE: QA, (DC( I Z Q)2 3 <br /> ASSIGNED TO: L 6;C` EMPLOYEE#:q f2`�11 DATE:(DU CDCt I Zm2?j <br /> Date Service Completed (if already completed): SERVICE CODE: t P I E: \(W.2 <br /> Fee Amount: (�j� Amount Paid I Payment Date q 2 <br /> Payment Type �1 Invoice# C 44 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />