Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property . <br />I4e kdcon c1.3 0 A <br />FACILITY ID # SERVICE REQUEST # <br />S*6 n LP17"— <br />RWNER / OPERATOR 1 0 CHECK if <br />"PO( cno' Ci 0 Cavba\ a- BILLING ADDRESS <br />FACILITY NAME i <br /> z-os PR iMof) Me ?c Ccco o 0 ( _ <br />SITE ADDRESS <br />itd / 6 Street Number Direction <br />L 1 ' IN cot R `P) A <br />Street Name <br />---cr cAc_ <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />9 5 Street Number ..3 40 t y akr- <br />Street Name <br />CITY STATE ZIP racy ct 53?- 6 <br />PHONE #1 Ex-r. <br />(2`(9C( ) 3 6 2 c)( 1 2_3 <br />APN # LAND USE APPLICATION # <br />ko, #2,.._ Ex, <br />(t)i o 8 i 2_ i 9 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESAOR 1 . <br />m 0 (\ i\ a eGt I( bok_ a \ CHECK if BILLING ADDRESS <br />BUSINESS NAME ('. 1- o5 DR(MoSie hi-e. K \ ()ay.\ Po 0 ck <br />PHONE # <br />(2o9) 3 6 R 3 2.. ct, <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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 <br />or activity 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 />PPLICANT'S SIGNATURE: <br />PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER El <br /> DATE: 0 (— 26-22 <br />OTIIER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAY <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />COMMENTS: <br />IAN 26 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ,4 A 5 EMPLOYEE #: q sAi.2 - DATE: 1 /212... <br />ASSIGNED TO: <br />U <br />too ot, L, . EMPLOYEE #: Lfgc0 DATE: 1 / 2,2.....„, <br />Date service Completed (if already completed): SERVICE CODE: V-3 P1 E:1 <br />t <br /> 0 1 <br />Fee Amount:S,L4p . 00 Amount Paid M (-{ c-rp _ Payment Date <br />Payment Type Vi*- Invoice # chsrek# 1 3'—St G-1 („ 2,.<1 Received By: 4,----/ <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)