Laserfiche WebLink
SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /1 <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESSN n f et-41j1-421 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or/MAILING ADDRESS (If Different from Site Address) <br /> l �� Street NumberT Street Name <br /> CITY � STATE ZIP <br /> PHONE#1 EM. APN# LAND USE APPLICATION# <br /> —(&b .. 953-7 <br /> PHONE Z ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME ` PHONE# �`' �� EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> �f !` /f 6 C ( ) <br /> CITY / STA /4 ZIP EMAIL <br /> A <br /> BILLING ACKNOWLED EMENT: 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❑ OPERA // A _ 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 igLqrmation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is proZ rny', <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C,0n St,d}Ck-:h Uh <br /> COMMENTS: 2024 <br /> SAN jOAQUI 7 <br /> MF�DEA' TY <br /> ENT <br /> ACCEPTED BY: BY EMPLOYEE#: DATE: (Dti <br /> ASSIGNED TO: Ci CA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:\&q)-2 <br /> Fee Amount: tkG2- QZ Amount Paid I (Q2 � Payment Date <br /> Payment Type Invoice# -Cheeky Aeceiveld By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 N,6I <br />