Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Is P112-le B-i K4 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAM <br /> SITE ADDRESS l E CICI l t- �} r` <br /> Street Number Direction L t7-v-Vsreet Flair <br /> (f—v-Clt Tqli _ ode <br /> HOME/ron^r MAILING ADDRESS (If Different from Site Address) <br /> Wcj Number �Stree Name <br /> CITY STATE ZIP Q <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REC1UEST9R� CHECK if BILLING ADDRESS <br /> BUSINESS NAME — PHONE# EXT, <br /> T11 C S RA <br /> HOME or MAILING ADDRESS FAX# <br /> 16L� L ( ) <br /> CITY TrjLk�:kU\A 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 /> 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3 12 C� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f 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 provided to me or my <br /> representative. pp�� <br /> TYPE OF SERVICE REQUESTED; <br /> COMMENTS: <br /> A ? VFO <br /> 6 <br /> y F�W QU/N c ?�2� <br /> �9CTy M�,�� 7)- <br /> ACCEPTED BY:1by kanot Nk. EMPLOYEE#: DATE:-31• 0.2� y <br /> ASSIGNED TO: C1 uud;C,` M EMPLOYEE#: DATE:312 t Z L <br /> Date Service Completed (if already completed): SERVICE CODE: �(� ( P/E: (0(D'3 <br /> Fee Amount:$1i�2.cz.� Amount Pai l�v? bd Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 �P- 11 O� O <br />