Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />A 6710'2 7 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />4 401 AG1 it-t-S inei‘ <br />FACILITY NAME A , <br />31 r)&t I perl%c ---kctt''-r icA 1-- • ° <br />SITE ADDRESS <br />I 44 Street Number Direction <br />rpy izotmk <br />Street Name <br />r c-14- -rn1 o <br />City <br />ols-YS) 0 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) (1-----,- oil) Street Number <br />r-/1 1 (ô r-1--- c) 16k <br />Street Name <br />CITY STATE ZIP <br />5/PSI CCA`& <br />PHONE #1 EXT. <br />n) Gi:-32__ -e.k.6t ( <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext. <br />(-6fr1) c1:1 S IL-1 7- <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />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 />I 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: <br /> <br />DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 proviN to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: /1A--'2J (-e-LkVI;k <br />f rrcc ii, r , COMMENTS: Ak oc) et_ J(044I ,2 <br />84;vdo <br />9 <br />2024 Eivil 4Q04, atitik ii.o,v cou <br />7.`lcsp,4,..44rALAI)- ,r,t,,E.Air <br />-A) Ea.-LA_ jc3 <br />ACCEPTED BY: , <br />---- <br />EMPLOYEE #: .., -,q_. g) (---8 DATE: / / z1/2_ 7../ <br />ASSIGNED TO: 6.-7 (-_,D F EMPLOYEE #: g, `3.- 7:3 3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 6) <br />P / E: <br />Fee Amount: <br />-'t• 4,. i 6 2 / Amount Pak" lb 2 , 00 Payment Date <br />Payment Type / / ' Invoice # Check # 1 -7 56-- 7 63 14- Receive B Alial . Air,/ <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />PRO S 3,19 S <br />Title