Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# //SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Ft <br /> n (�,l.� <br /> SITE ADDRESS N, T)" pa( � T" 1 <br /> Street Number Direlion Street Name Ci/ Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) G 3�� ''0 SS(EGD u kL LlLi, <br /> u Street Number Street Name <br /> CITY STATE CA ZIP <br /> COfVCe�Q <br /> PHONE#') ' APN# LAND USE APPLICATION# <br /> (qac) <br /> PHONE#2 ERT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E'r' <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEN'IENT: 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 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: 0 G-ZS- =6Ly <br /> PROPERTY/BUSINESS OWNF.RIM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ'4PPLIC.aNT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. _ AOA I <br /> TYPE OF SERVICE REQUESTED: vV �)Jv II�iVC <br /> COMMENTS: <br /> sAN APR 2� 2020 <br /> AL / ON pMFNoUNT <br /> AR C <br /> ACCEPTED BY: � EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /"3 P I E: <br /> Fee Amount: T`-2 Amount Paid/"p LjD Payment Date <br /> Payment Type Invoice# Check# 23 D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 7/200 3 <br />