Laserfiche WebLink
ANIMillaba <br />ERATO ANAG 0fOTHE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />ri c-G-i R. <br />SERVICE REQUEST # ,--v) ,r ,,,,f.0._:.4--- <br />OWNER / OPERATOR <br />P\ c-2-.. Go7_NLE2_ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> <br />SITE ADDRESS 730 <br />Street Number <br />S <br />Direction <br />C (_._( FOCZ\ 1 1-\ t <br />Street Name <br />S\ 0 CK TOKI. <br />City <br />C 4'73 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />'2_‘--1 \A/ 3p,mEci-oWN ST NPT 303 Street Number Street Name <br />CITY STATE ZIP STOCK 0 CA CF\ cit3 2-D7 <br />PHONE #1 Exr. <br />(2.M ) q 3Q\C Lk Ct, <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />U <br />i-\ <br />tV\ l'ik A Z. CD 0 NCO\ LEL <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME — 'LL x \ CO <br />EXT. P(H27E4 ) ckck,..5 . ,-2. \ uk s <br />HOME or MAILING ADDRESS <br />2i-A w .)i‘v\EST(ANIN <br />CITY STocKTON STATE C/_.\ ZIP <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 <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 app n and that the work be perfortne2 will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S and FEDERA <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER!: <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ ite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th ime it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />Ett <br /> %; <br />COMMENTS: <br />tili I i ? <br />04' <br />a _ 47 i <br />.*4044414074,17„, <br />ariNityliesper <br />ACCEPTED BY: C.' it,‘_ v'S C-Itz, EMPLOYEE #: DATE: 2 ..-2_ -7 .. <br />ASSIGNED TO: Bc, Ca-At--- EMPLOYEE #: DATE: -), -2 -7_ 7.3 <br />Date Service Completed (if already completed): I t SERVICE CODE: DC7 ( P / E: / :::, 0 .5 <br />Fee Amount: <br />166?, <br />Amount Paid /, . Payment Date <br />Payment Type ' /k) Invoice # Check # Received By: <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />THORIZED AGENT 0 <br />DATE:02 2-7 2023 <br />Title <br />F120 9-I 02(0±