Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PROSLI-aoo <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TS R(2)0 2 7 55 4 <br /> OWNER/OPERATOR <br /> a�^ �i Q CHECK If BILLING ADDRESS❑ <br /> . 1 <br /> FACILITY NAME ) �►/ �, <br /> SITE ADDRESS 1-71 S / �In 157- //o C 1G <br /> Street Number Direction (/ // �/ Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 o Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAILTBOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP 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:L/L L l DATE: /2-- 3 <br /> PROPERTY/BUSINESS OWNER❑ 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 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 proviftA me or my <br /> representative. IArrq' <br /> TYPE OF SERVICE REQUESTED: I VE <br /> COMMENTS: ukc <br /> � 2023 <br /> fj y4RQUII y COQ <br /> h 0��M AL <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: 1jI 3 DATE: 1'24 'LI Z3 <br /> ASSIGNED TO: l ^ EMPLOYEE#: DATE: i 2 Z 23 <br /> Date Service Completed (if already completed): SERVICE CODE: b( PIE: I b3 <br /> Fee Amount: Amount Paid 1U2 . <br /> _ Payment Date 12 2l 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />