Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />".-...c.' <br />SERVICE REQUEST <br />Debg <br /># <br />0 -5- <br />OWNER / OPERATOR)c puri4. ki IV& 61 CHECK if BILLING ADDRESS <br />FACILITY NAME >c..:- vii4+t4.4__ N.z..t p p! Ni <br />SITE ADDRESS 9_10 1 <br />Street Number Direction <br />p f\ (-0-, (_.., kv t <br />Street Name <br />S o cr Tc Li '`) <br />City <br />S q 20 t <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 4 "Li -4_ <br />Street Number <br />oki Cki DK6?& v) (0-.1 VI; <br />Street Name <br />CITY (.) <br />-(--- All <br />STATE c 6_ ZIP q, ‘..i_ E - 3 1 <br />PHONE t Ex-r. $it+,„„ <br />( al 0 ) 105 5 - 3 )) b 2- <br />APN # <br />og-/-s----00 —0G <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(L*) b '3--1 2- BOS DISTRICT/ LOCATION CO E <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (._1(‘..\ 7 0 N (,---, CHECK if BILLING ADDRESS <br />BUSINESS NAME ,.1 ck.) LD E,1\ i r, R., C \ <br /> <br />FAENE# <br />(SAG ) <br />EXT. <br />511 U9 <br />HOME Or MAILING ADDRESSk <br />1.—C K.,.. , 1--htk_ twAi FAx# <br />Ci C, \ t L. F.GLIA.}.-- <br />CrrY --f-t-tuto-vv-1 <br />STATE L tr ZIP et i+s-3t <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that aI site arid/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that th work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL Vaws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR / MANAGER— OTHER AUTHORIZED AGENT 0 <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at pi same time it is <br />provided to me or my representative. Ay <br />rtrc&"ivi- TYPE OF SERVICE REQUESTED: CO/ pke, c_ c_,e_ ,ilv .t) <br />COMMENTS: 08 44A, 2023 , JoAci _ <br />/1471/AbrAi COu rif bk.p4f47-4LVT), <br />'VO4 47- <br />ACCEPTED BY: EMPLOYEE #: (F-gcF —7 DATE: 3 )-770_ <br />ASSIGNED TO: e a--ef----\"/ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ,,c------2____3 P / E:/r 7 07 <br />Fee Amount: 41-6, E"--- ,k---, Amount Paid -, 1---kl,c... _- - Payment Date g i 2-7 <br />Payment Type (yv -- Invoice # ,C47E-CC& 1 "-C,(F,f Q --+.1 -9- Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />DATE: