Laserfiche WebLink
SAN J(I;IQIIIN CUUN fl'EWIRONNIENTAI,HEA1,TI1 1)BI'ARTRIl,:N1' <br /> SERVICE REQULST <br /> Type of Business or Property FACILITY ID!t SERVICE REQUEST!t <br /> OWNER I OPERATORCNFCK II BILLING ADDRESS O <br /> -0-12� ca �rl tun ---- <br /> FncunT• A6tE <br /> SITE ADDRESS �� C(f 1,Ck 1�.� L� I �j`Z E�b <br /> Slrael Homho Ohoctlon \ \ St".1 N.M. CII ZI,Codo <br /> HOME or MAILING ADDRESS (If Difforonl from Silo Addross) <br /> UShoot Ibmo <br /> 1— � ( Sl�val llumbor <br /> CITY STATE ZIP ^ �' <br /> OC o <br /> PHONE#I E"c'• APN A LAND USE APPLICATION 11 <br /> Q�► � 33I4 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> O g 11 <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR same as above <br /> CIIECK If BILLING ADDRESS <br /> BUSINESS NAME. PIfOIIE It EXT' <br /> HOME or MAILING ADDRESS FAX 1! <br /> CITY STATE ZIP <br /> BILLING ACKNOII'LEDGEN IENT: 1, the undersigned properly or business owner, operator or authorized agent of same, <br /> acknowledge that all site antUor project specific ENVIRO MENTAL HEAL'ill DEPARTMENT hourly charges associated with this project <br /> or acti0ty will be billet/to me or nn•business as identifi on this form. <br /> I also certify that I have prepared this applicatio and tl the wor performed will be clone in accordance with all SAN JOAQUIN, <br /> COUNTY Ordinance Codes,Slandards,STATE a d aws. <br /> APPLICANT'S SIGNATURE: DATG: <br /> PROPER-1I'/Bvsr%ESS OWNER[] OPEllT /IVIAN,.GER� OTtlt',It AUTNONium AGENT� � EN <br /> Il;IPPL/C IAT IS Not the DILL/AG AItTY proof afarrl/rorira/iorr la sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geolechnical data and/or environmental/sire assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL I-IEALTII DEPARTMENT as soon as it is available and at the Same1 !is <br /> provided to me or my representative. M <br /> ENT <br /> TYPE OF SERVICE REQUESTED: Change of ownership ED <br /> COMMENTS: 2023 <br /> SANJOAQUIN UNTy <br /> ENVIRONME TAL <br /> HEALTH DEPAR'MENT <br /> ACCEPTED BY: DA EMPLOYEE#: 9825 - DATE: 5/24/23 <br /> ASSIGNED TO: DA EMPLOYEE#:. 9825 .DATE: 5/24/23 <br /> Date Service Completed (if already completed): '•URVICE CDDB: 1061P E: 1802 <br /> Fee Amount: $156 AmountPald Pay.ftt�nE Dote rJ n <br /> Payment Type C Invoice 0 CFjaeR#`s 3��' ; "I�eciSfved 6y, w <br /> EHD 49-02-025 $R FORM(Golden Rod) <br /> REVISED 11/1712003 <br />