Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />sRoos -7 4 (CI (P <br />OWNER! OPERATOR jo . <br />CHECK if BILLING ADDRESS le_l_A /C 6_A a rd Li' 161 / <br />FACILITY NAME n Qa r pm,/ e y Co me d / C 1(4 II <br />SITE ADDRESS / 2-7 <br />Street Number DI/reiction A4 a o 5--/- Street Name A4--/-ec-ok <br />City <br />q 5-136 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7 / 5 c y ) / a r a. ve_ Street Number Street Name <br />CITY 44 Pita 11 -le C. <br />TEA. ZIP m <br />PHONE #1 EXT. <br />(2.e) ‘ Z2- s 7 q 5 APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />(209 ) 6og - *2 %-‘ EMAIL <br /> A el re; cA 0-1-ma, BO/ DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />If <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 FED AL laws. <br />APPLICANT'S SIGNATURE: <br /> / <br />DATE: / / Zoz 3 <br />REQUESTOR ii , / / ------ <br /> <br />ff Chard /e 1 C / i <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME r-‘ Co L__)eoP Ry9/0/ medy elol PHONE # <br />( ZC'eh 6 22 -C-711-5- <br />EXT. <br />HOME or MAILING ADDRESS <br />/ S. i)c) /a /- ilve <br />PAX # <br />( ) <br />CITY i a NTE <br />'IPC3 3 6 . MI- /-echo / icf e Actm4 <br />Title <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 <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prov <br />representative. <br />i litiv 09 4u 9n23 TYPE OF SERVICE REQUESTED: p i 0, ChecK <br />skv JUA COMMENTS: ki,f.NV/Ro <br />Qu <br />lv: COUNT.„ <br />ARNENT <br />1)13YAS Sabrw,t.ka e\ed-ron\ ca‘lj to \lido-Q. 1L ci --3 <br />ACCEPTED BY: V idcd ptdraza EMPLOYEE #: Co 13 DATE: I I _ q _ ao 3.3 <br />ASSIGNED TO: a ,.,das -pe6r a ..za EMPLOYEE #: co a i -3 DATE: 11_01 -o3 <br />Date Service Completed (if already completed): SERVICE CODE: 53 PIE: 1b01 <br />Fee Amount: LS eks(9 Amount Pai4-t14-g‘,. Payment Date i V3/43 <br />Payment Type ex--1---- Invoice # Check # (7 1-7 6---,,g5-5-- Received By: <br />END 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod)