Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 000 3231 SRmmYC��3C�m <br /> OWNER/OPERAT R <br /> 51101— <br /> C-1N`e` LLC- <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Cn mo C ( O ` i 0 <br /> fu <br /> SITE ADDRESS S Z S W k' 5't Cy C1 S 3 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 1&&0-7 UJ 6( Q V-�- <br /> Street Number Street Name <br /> CITY �rG CYTATE r I1 0 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION-\# <br /> PHONE#2 EXr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ► <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS WJ <br /> BUSINESS NAME a PHONE# EXT. <br /> �ro, e- ( ) 3 -31 a-&13 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATt. ZIP EMAIL <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: ^"'Y �r,8,�,,;,,� DATE: <br /> PROPERTY/BUSINESS OWNER F3 s 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 provided t0 me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: yimj 'om <br /> COMMENTS: RECEIVED <br /> G IG ECEI•ED <br /> aa,ve o6 OwnersAip UN 2'0 200 <br /> 23 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> �l,T <br /> ACCEPTED BY: 8Vi C+.t'I n e EMPLOYEE#:qs(o rj ATE: (p g G 3 <br /> ASSIGNED TO: /,-QC/C'C-L�Yjr)e EMPLOYEE#: 4589 DATE: Co'ZrO 12023 <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 P I E: m2- <br /> Fee Amount: I Amount Paid /S Payment Date & Z Z <br /> Payment Type Invoice# l # �Lcs eceived By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />