Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �A FACILITY IID# SERVICE REQUEST# <br /> : ] FA oU V W`1 0-1 � 00<3L_J,5—Il <br /> OWNER I OPERATOR <br /> � U,'107 <br /> CHECK If BILLING AI0 <br /> DRE55� <br /> DJ <br /> FACILITY NAME Mrt✓ S10JIT <br /> C / 6- p ` es&, <br /> o nio "c <br /> SITE ADDRESS A00 r `ocAve, <br /> 4- eS -Dof <br /> I�0/-5 <br /> 4LAL-) <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP _ <br /> i. <br /> PHONEA E-. APN# LAND USE APPLICATION# <br /> ( D <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /� <br /> Gj��� p� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1*41Ael�iCD5 1rPSCOS All 0 I � I"la �# ©EXT_ <br /> HOME Or MAILING ADDRESS J FAX# <br /> T ( ) <br /> CITY STAT ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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: c DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/site 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: -F-Do CAVI CEIVED <br /> COMMENTS`OAV4 NOV 3 0 2021 <br /> C` `�" t)� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: J�AEMPLOYEE DATE: 21 t7 <br /> ASSIGNEDTO: IS EMPLOYEE DATE: JV L <br /> Date Service Completed (if already completed): SERVICE CODE: O W PIE: OZ <br /> Fee Amount: 1 JZ Amount Paid s Payment Date I L 3 O -�� <br /> Payment Type l 5 A— I Invoice# c4eeck# /3 5 3 S Received By: <br /> EHD 48-02-025 5� Z� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />