Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />geopiVI-sq <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Tacos <br />SITE ADDRESS Z 21 <br />Street Number Direction Coronack) Wc") Street Name j <br />—1--(0-6 <br />Cit <br />q c:D .3 1 LC <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />PHONE #1 EXT. <br />((L59 339 skiciut <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Man a- NlectiYItt' CHECK if BILLING ADDRESS <br />BUSINESS NAME • • <br />-171 ( OS midi") -mmilie, ii '2 LL(can <br />PHONE # Err. <br />5qq-02-SS <br />HOME or MAILING ADDRESS <br />211 to E. Hiner A- v -e . & 2- <br />FAx# <br />( ) <br />CITY shcAz4orx STATE (IA_ <br />ZIP an 2 - D 5 tkr;:" onc es I UriValol e rteActit <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 />I 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 />fi DATE: OS /2 2:3 <br />PROPERTY! BUSINESS OWNER 0 ATOR / MANAGER 0 OTHER AUTHORIZED AGENT)Gr Cleprirtclvy-- <br />If APPLICANT /S 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 ispaikifilihirio Air my <br />representative. <br />TYPE OF SERVICE REQUESTED: find 17(01 ("\ cile (-lc ----N.civtD <br />COMMENTS: tip MA Y 2 4 2023 ()\-,12_ SAN JOAQUIN COUNTY <br />H ENVIRONMENTAL EALTH DEPARTMENT <br />ACCEPTED BY:VA EMPLOYEE #: DATE: G 2..(.1 23 <br />ASSIGNED TO: j e„ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Gz P/E: i (0 0f <br />Fee Amount:1,Amount --- Paid Lh F 0 -7) o Payment Date 5-44/23 iclioi <br />Payment Type Invoice # Check # /(:) 7_6eiDx3-1 Received By: <br />APPLICANTS SIGNATURE: , <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23