Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR `' <br /> yf � via / t, I�d��C CHECK if BILLING ADDRESS <br /> FACILITY NAMEY� )T 1C <br /> SI TEA DDRESS <br /> —a" Street Number Direction / Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) j / 1 p d �c U b4 <br /> J Street Number I Street Name <br /> CITY STATE ZIP <br /> o <br /> PHONE#1 EM. APN# LAND USE APPLICATION# <br /> PHONE#Z Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> (), ) -151 — rG2 bur. Y) ' <<_ ►�- ! ��t_ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS11 <br /> BUSINESS NAME y J n 1 l PHONE# EXT. <br /> �y Z� l t r �� c `G�v/ Inc- ( 1 -) S/- / <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE C zip 2 SEMAIL _ <br /> I U �.v�i 2- u Y 1✓ 1� .Pv� :,� a..`L (.yr., <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: 51/2 (1 1/2] <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: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 provided to me or my <br /> representative. n rr-. <br /> TYPE OF SERVICE REQUESTED: l�j n S �VCI o y) <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: C 2- <br /> �j Z <br /> ASSIGNED TO: �2 EMPLOYEE M C((6,2 DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: /� <br /> S <br /> Fee Amount: / "1 Amount Paid lS�,oU Payment Date 151Z&12-3 <br /> [/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />