Laserfiche WebLink
(\ev — rweaz <br />PIZ <br />SERVICE REQUEST <br />Type of Business or Property <br />" ,4 <br />0 l',\ -.1--i 0 C k t-C) <br />FACILITY ID # SERVICE REQUEST # <br />saoa)86G,32 <br />CHECK if BILLING ADDRESS <br />OWNER / OPEIATOR <br />i0Ct...) <br />r <br />eaV RV ()) Cin S 0 / 0L I <br />FACILITY NAME - <br />-Mr Y, Co o <br />SITE ADDRESS <br />'2-. 1 St reet Number Direction <br />qraNckac. iLic-, y <br />Street Name <br />-1-1,--a C K <br />City <br />953 7/ Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Ck y <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />Q t"/CP 3 6 2c1 ( t3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />Ike- (' (3 0 c e55- ( 0 p <1 ) ( <br />BUSINESS PHONE <br />NAME4'd5 IN ( r(10 3 Te )( -Me 71_ <br /># <br />( ) <br />Err. <br />HOME or MAILING ADDRESS 32 I 5ranoJcA Li a y <br />FAX # <br />( ) <br /> <br />-r- -- STATE - <br /> <br />CITY • i;cr. Y ( 'CI - Z I P CI--5—t) ri 6 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 Of 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 an FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br /> <br />DATE: 0 LI q <br /> <br />OTHER AUTHORIZED AGENT 0 <br /> <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 assessmen8iformation to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr I4tftJor my <br />representative. <br />TYPE OF SERVICE REQUESTED: rceic( Ple-,-/-1 Cil_e_e_i___ - '4711/So po._.(2_52„.. <br />'4 Pi? <br />COMMENTS: 19 2023 81IN JO A <br />/VAL v d?04/44 COUN <br />7-li bePA0.47;9( 711 . t ritfENT <br />ACCEPTED BY: --66caii e) EMPLOYEE #: DATE: <br />ASSIGNED To: iv V e.c.,6.6.„%., EMPLOYEE #: DATE: ,-/////a0.2 .3- <br />Date Service Completed (if already completed): SERVICE CoDE: PIE: /60/ <br />Fee Amount: $ tkpe, OCO Amount Pai q-4,g. 0D Payment Date <br />0/2, <br />Receiv d By4-0--- Payment TypeCizelft Invoice # Check # / 60 -7 c? + <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23