Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F:A0(D 15 511 S12QXD�3{�,(ol <br /> OWNER/OPERATOR <br /> `,� �� /t CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME //t �f <br /> SITE ADDRESS <br /> 3?,G S CcL` t �Uf✓1!L'l S-1- S.}-cc..\C.-1ur� `�SZG`j <br /> Street Number Direction Street Name City Zip Code <br /> HOME or ML <br /> ADDRESS (If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITYC S Rim <br /> l�L��� STATE ZIP 2c)PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ('1,1►°I) `5h1- lead I <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR7sy—at V � CHECK if BILLING ADDRESS <br /> BUSINESsNAME ,A PHONE# EXT.U <br /> HOME sir AILING ADDRESS FAx# <br /> l URM <br /> CITY STATE up ZIP4M;) EMAIL T aBILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or au horized 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 <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: 6 3 j 2� � 2v Z- �! <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�gr V_Ided to me or my: <br /> representative. 1 Y <br /> TYPE OF SERVICE REQUESTED: "r�7 CC)0SUd+CUt7Un CEI / <br /> COMMENTS: MAR <br /> 5 2L1E0M24 <br /> JDPVN VI � MEI V7T- <br /> y <br /> ARTT <br /> ACCEPTED BY:'ijr i Q"rl., M EMPLOYEE#: DATE: 3 I Zc -2 Li <br /> ASSIGNED TO: Lys iC+ l3 EMPLOYEE#: DATE: 31-ZS 12q <br /> Date Service Completed (if already completed): SERVICE CODE: (Z�6( PIE: <br /> t CD3 <br /> Fee Amount: 3I(oz mm Amount Pai V61?, 66 Payment Date 3 Z <br /> Payment Type Invoice# Check# ��g(o� j � Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 '(7j� <br />