Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c 1 SCS 8 5�1 <br /> OWNER/OPERATOR <br /> /j/ /,_ //� meol CHECK If BILLING ADDRESS El <br /> FACIU NAME <br /> SITEADDRESS <br /> �"V— <br /> '4ljP— ON Ggg5P-7 <br /> I Street Number Direction i Street Name ICi //�� Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> G a v <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S �v p n C,� 'ZIO <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (3o ) (�a� �� 6 <br /> PHONE#Z EXT. ��EMAIL��L ��w/ ��� ���� BOS DISTRICT LOCATION CODE <br /> r\ ` �' /' 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME �/ r �� � MQ� PHONE# EXT. <br /> HOME or MAILING ADDRESS n !� i c p Y FAX# <br /> CITY C�P a STATE ZIP (� Cn ( � EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or businessl 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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: _� DATE: ` f N- <br /> PROPERTY/BUSINESSOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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 provided to me or my <br /> representative. <br /> 34 r <br /> TYPE OF SERVICE REQUESTED: euj Q vJh�' C_dVt ENT <br /> COMMENTS: ED <br /> svv o N 0 S 202 <br /> 4 <br /> JR �ICpENV/ DuN7YME�7h0�A �N <br /> ACCEPTED BY: n, �/ EMPLOYEE#: DATE: I--S-,2 <br /> ASSIGNED TO: 1,�1 C�tr J EMPLOYEE#: DATE: S ^2— <br /> Date Service Completed (If already completed): SERVICE CODE: l PIE: 6 C j, <br /> Fee Amount: (� Amount Paid <E1 ((�a Payment Date /�2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />