Laserfiche WebLink
SAN JOAQUIN L OUINTY CNVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property - <br />FACILITY ID # <br />SERVICE REQUEST # <br />LAcCEPTED <br />HOME or MAILING ADDRESS <br />35 11 F YI Gil co S 3 S <br />'ku . <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />FAaury NAME Sn ft"V-V-A,Qu�R�P� <br />U <br />1 U J&J CIS -7-7 <br />SITE ADDRESS 2140 <br />e hwi <br />13"L <br />—'C�a L.y <br />\. y1^ / �-� <br />Street Number <br />Dlreetlon <br />DATE: . � ^ 'J� <br />��' l <br />Street Name <br />D <br />ZI Dodo <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />\ SS 11 <br />\ G r lCA `j E 1iQ <br />Payment Date <br />1S10- S -2Q- —23 <br />Street Number <br />Street Name <br />CITY Mantecazip <br />STATE ct 33 <br />PHONE#1 Ext. <br />1615 ) (15 -'-'('g %4 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Ext. <br />( )6 o-S� 33 <br />EMAIL <br />C,(A an.rtonstN&T3&'3MAiJ- oM <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RVOTIF,STOR <br />REQUESTOR CQ f C p nT✓a / / p -� <br />1 ��e/ in ) cTl)ir CHECK If 81�LLWgC. ADDRESS❑ <br />BUSINESS NAME GCA I C n �i G. <br />�(T ei I v) "� "Lt \ e t <br />LAcCEPTED <br />HOME or MAILING ADDRESS <br />35 11 F YI Gil co S 3 S <br />FAx9 <br />f ) <br />CrtY Mod eS-�'o STATE ZIP <br />EMAIL <br />BILLING ACKNOWLEDGEMENT: 1, the undersioned Dronerty nr httcinace nwnar nraatnr nr �rehrroar �,a..t f ��.a <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 />1 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 FED RAL laws. <br />APPLICANT'S SIGNATURE: Gam. _ DATE: <br />PROPERTY/ BUSINESS OWNER Q 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 environmentaVske assessment information to the <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time it isrovided to me or my <br />representative. 9A T,_ <br />TYPE OF SERVICE REQUESTED: r\9'.) 4�3 0 (\ 4 r CA ". `.F - <br />Ckrl� <br />C or -F 00 <br />EHD 48-02-025 <br />03/22123 <br />���1g353 <br />SR FORM (Golden Rod) <br />c� <br />sAN MAR 29 2023 <br />LAcCEPTED <br />HQNU/N COU <br />FA T �V/RO PARrMENT <br />BY: <br />L y� <br />EMPLOYEE #: 14,— 16 <br />DATE j, %q 7 <br />C3 <br />ASSIGNED TO: <br />\. y1^ / �-� <br />EMPLOYEE #: \ , `' q <br />`t V <br />DATE: . � ^ 'J� <br />��' l <br />Date Service Completed (If already completed): <br />SERVICE CODE: Q V <br />PIE: p <br />Fee Amount: <br />1 Amount Paid <br />Payment Date <br />1S10- S -2Q- —23 <br />Payment Type <br />C C Invoice # <br />Check # j �� 7 Received By: 7J -. <br />C or -F 00 <br />EHD 48-02-025 <br />03/22123 <br />���1g353 <br />SR FORM (Golden Rod) <br />c� <br />