WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST -nee_Kk PE Type of Business or Property FACILITY ID # SERVICE REQUEST # SR VI) $9- 2.--i-E3 ovy,NE1R / OPERATOR ` qr1-1-b-rti 0 CHECK if BILLING ADDRESS kciraik 3 uc,,,,n, a 0 rti 1 FACILITY .NAME, Tap,tyr el y 1 i pi- / -e,-) et la/ SITE ADDRESS LI 0 I) U.) Street Number Direction 1 I Ill Sttreet Name .-----, Y acci 95-aci Zip ode HOME or MAILING ADDRESS (If Different from Site Address Street Number Street Name CITY STATE ZIP PHONE #1 En. Wei ) (0 2oll APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 11)(.4 A NI ivyv 6 Po 117 ( 4 ,0 CHECK if BILLING ADDRESS . BUSINESS NAME Ni g , C.7 c-ini vi PHONE # 1 ) (0 2 7--) EXT. HOME or MAILING ADDRESS FAX # ( ) CITY STATE ZIP EMAIL BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applicatio and that t k to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE a FEDERA APPLICANT'S SIGNATU DATE: PROPERTY! BUSINESS OWNER 0 If APPLICANT is no PERATO he BILLIN ANAGER 0 OTHER AUTHORIZED AGENT 0 ARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: PI an 9--e-,,i ., e-LAD Cv-A 0 to I 1 e V-c 06 ) R.ECEIVED COMMENTS: OCT 0 6 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: b y , ck nne 1%-A . EMPLOYEE #: DATE: ASSIGNED TO: -3- e c• c: C EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 1062:3 P/E: Fee Amount: $48(0 , (ba) Amount Paid ii g &. Payment Date Payment Type c c Invoice # Check # Received By: FA,0000-11- on (7 00 11 ((A EHD 48-02-025 SR FORM (Golden Rod) 03/22/23 P62oRP-I2l