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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 'PROSgoq-+ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /L-7 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> TCA v r <br /> >SITEADDRESS C �� <br /> /2 Street Number Direction J Street Name t Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -2� <br /> 1�' 7 T Street Number 181C(C441p*Q�XStreet Name <br /> LITS C /� C STATE ZCIA 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (zccr) 52 6 — 7 7/ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> tr5 4h 13o <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDR SS FAX# <br /> ( ) <br /> CITY S STATE ./, ZIPj5.3 Z 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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: T 2L DATE: //- -7e:2 ZD 7--? <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 assessor jnformation to the; <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS Fo i- e Or my` <br /> representative. R <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Nl V V I v SqN✓ 2023 <br /> w��1�I <br /> �N�� /NNCTio� cOUH�n , <br /> 'YR �N <br /> ACCEPTED BY:Laua EMPLOYEE#: DATE: I J 23 <br /> ASSIGNED TO: EMPLOYEE#: q DATE: I III �O 23 <br /> Date Service 6onn' 11 XG <br /> feted (if already completed): SERVICE P/E: <br /> Fee Amount Amount Paid /�� D� Payment Date D12-3 <br /> [Payment Type Invoice# Check# 2 � — Received By: <br /> Alo <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> c r� <br />