Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRwa +k3>cv <br /> OWNER I OPERATOR ///777 <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> U0 0 -"17 <br /> SITE ADDRESS 29mm {,7/ardi nn /� c ,ryI �,�-�C }n 9SZm S- <br /> Street Number Direction S�trre�ettNar4e City Zip Code <br /> HOME r MAILING ADDRESS (If Different from Site Address) <br /> at Street Number Street Name <br /> CITY STATE ZIP <br /> qExT. APN# LAND USE APPLICATION# <br /> P _0 < gg�Z <br /> PHONE#2 ExT• EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR O r` <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P E# Ex-r.'� C' In L <br /> 2 <br /> HcQUE or MAILING ADDRESS FAX# <br /> CITY y o T&E ` EMAI i C ](0 <br /> 't �n <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, STAT laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ A AGER ❑ 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: <br /> COMMENTS: � +Q <br /> SEP 0 5 2023 <br /> SAN EAMRON JOAQUIN COU" <br /> HNTAL <br /> EALTH pEp7Y <br /> E <br /> ACCEPTED BY: C de'(Vr.�c �/ LLQ EMPLOYEE#: DATE: <br /> ASSIGNED TO: r 7 EMPLOYEE#: DATE: '7 2 <br /> Date Service Completed (if already completed): SERVICE CODE: `n PIE: ' <br /> 03 <br /> Fee Amount: -� t Amount Paid / Payment Date 2 <br /> Payment Type Invoice# 1 Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> `c� <br />