Laserfiche WebLink
FR 0 S 02 2L,2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A�mm8m SCZt og-4-2 <br /> OWNER/OPERATOR r �-� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME . <br /> �t� 2 <br /> SITF� c+e `� ) ' t— J <br /> / Street Number Direction Str t am Cit Zi Codc <br /> Ho M Or MAILING ADDRESS (If Different <br /> from Site Address <br /> `W— Street Number Street Name <br /> STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 0 211- �3b�� <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME N trl� <br /> Q <br /> HOMEO MAILI DRESSFAX# <br /> 3 U C-�►21z� C--��( t ) <br /> CITY STATE 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STand FEDERAL la <br /> APPLICANT'S SIGNATURE: G �� DATE: <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: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. PAIsg— <br /> TYPE OF SERVICE REQUESTED: C he nc' e of �E <br /> COMMENTS: <br /> a 3 0 ?D?3 <br /> M� dOAQU/ly C <br /> CTH p�R �N�l' <br /> FNT <br /> ACCEPTED BY: Ibrl ann-e M EMPLOYEE#: DATE: `Q�30 1'2 3 <br /> ASSIGNED TO: G 1 C,"1 T. EMPLOYEE#: DATE: JT`-?Z�23 <br /> Date Service Completed (if already completed): Af SERVICE CODE: PIE: l�G?2— <br /> Fee <br /> Fee Amount: I (p Z Amount Paid �2 Payment Date 11)13C>[25 <br /> Payment Type 1, Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> \S <br />