Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1--h (')')2I 3� <br /> OWNER/OPERATOR ,� <br /> v CHECK if BILLING ADDRESS <br /> FACILITY NAME . Ju <br /> SITE ADDRESS III O 1�� w � n ,/\ (/�/� Iq%1umber vection treet Name � y \� Cit T��, od lJ <br /> HOME or MA ING/ADDRESS (If Different fr me pdd ess <br /> (� � Street Number Street Name <br /> CITYl �rfT ^ STA Z4 S <br /> PHONE#1 X'\J) I (_1 (7E,, APN# LAND USE APPLICATION# <br /> -O <br /> PHONE#2 Exr, EMAIL BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `- �+ PHONE; Li _ I Exr' <br /> HOME Or MAILING AQDRESS31 r ,� (A �Vc (axe# ) <br /> CITY S rua t I/ STT ZIP �1 (�` 1` EMAI <br /> 01111 1 <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, ST E nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ PERATO 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�*0gtl to me or my <br /> representative. ��/777 rM <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �A►�OAQU� 6?0 a ON N�U <br /> RC1�O��M�►r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: OA <br /> EMPLOYEE#: DATE: <br /> Date Service Com_pl`eted (if already completed): SERVICE CODE: PIE: o L <br /> Fee Amount: kTP l Amount Paid Payment Date 2 <br /> r <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />