Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J9M83TkI <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRES"75. P'-7) s' (.�cl�rrarr��ss f2d --53-7"7 <br /> Street Number I Direction 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 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) oI of <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME—j'� � ! 1li ln0� �� `HON,D; ./ C q ExT. <br /> V' <br /> HOMEOr ILN ADD S J J/1 ►►"LL FAX[# <br /> CITY j/C9�rn�'rG T E / EMAILe. <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, Standards, STATE and FEDERAL aws. / �j <br /> APPLICANT'S SIGNATURE: DATE: �` 3//�` <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER [3OTHER AUTHORIZED AGENT El"' <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 wprovided to me or my <br /> representative. �'fY <br /> IV <br /> TYPE OF SERVICE REQUESTED: S S ��-S yC <br /> COMMENTS: � J / 3 <br /> If <br /> -SU` ' ?023 <br /> 11, RONME OUN1Y <br /> VE ,14 <br /> PAR M NT <br /> Of <br /> ACCEPTED BY: 15'aEMPLOYEE#: DATE: Z3 <br /> ASSIGNED TO: s' I2ltig EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 45-2-3 P I E: ��Z <br /> Fee Amount: cfAmount Paid (-Q Payment Date L <br /> Payment Type Invoice# Peh # C (S LV3-4 eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />