Laserfiche WebLink
'V1,10% 0522�1� � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> h r `��RW&�cot( <br /> MO�,i �OQC7 �aGi� 1 � . <br /> OWNER/OPERATOR C <br /> "-jv J (� <br /> FACILITY NAME CHECK If BILLING ADDRESS <br /> � tY 1�v`UJ <br /> LA v f c, <br /> SITE ADDRESS ^^ C �,�{�-,.� <br /> Street Number Diren NYdtVqJ treet e 5�C"�`'L`it Zi de <br /> HOME or MAILING ADDRESS (If Different from Site Address) _ <br /> P, O15372— Street Number Street Name <br /> CIT <br /> 3tock--r $T�T ZIP � ��^ <br /> PHONE#1 A f,v ` EXT. APN# LAND USE APPLICATION# \`J <br /> (200) Z&12,- 010t I I <br /> PHONE#2 EXT. MAIL BOS DISTRICT LOCATION CODE <br /> (UOL) 311111 - 43S-0 1rV1CAr1W10Je0L look.CGm <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ip�� Lo^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME C, l(J PHONE# EXT. <br /> gvi cwi& ) TI4co Sk20G1 - 01 <br /> HOME or MAILING ADDRESS FAX# <br /> CIT )fito*o1 STATE Cpr ZIP ��''j�S EMAILJMOV1 � � <br /> 5VtoIL& v <br /> BILLINGACKNOWLEDGEMENT: 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: _ DATE: <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 provided tolne or my <br /> representative. A <br /> TYPE OF SERVICE REQUESTED: (� 0�.�1�ut►/ C14 <br /> COMMENTS: .,/7N , <br /> J0 ,?OZ <br /> �rhD pMFCr4 <br /> ARrMENT <br /> ACCEPTED BY: ✓ S G EMPLOYEE#: DATE: <br /> ASSIGNED TO: �-i a EMPLOYEE#: DATE: -- ' <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE:1 41 <br /> I(„ <br /> Fee Amount: L� Amount Pai /(o� � Payment Date w <br /> Payment Typ (1 + Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />