Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Typeen%off�Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME Or MAILING ADDRESS <br />SERVICE REQUESTTA# <br />hf k7aU ((A f1� <br />Q <br />j%I <br />pvt2 1 <br />OWNER I OPERATOR <br />DATE: <br />` n <br />-Lo� <br />CHECK if BILLING ADDRESS <br />C <br />Fee Amount: ' G <br />Amount Paid <br />FACILITY NAME <br />Payment Date <br />U <br />SITE ADDRESS Gt1 <br />24 3�5 r1 <br />Payment <br />Payment Type <br />243"5) 1. ✓'i'q9, �`.5—c-d- <br />ck # 3 5 p <br />CQp <br />ACA(`t� <br />0 <br />Stlrca2 Number <br />Direction <br />Street Name <br />cl <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />E>R_ <br />APN # <br />LAND USE APPLICATION # <br />hot ) 510 -9266 <br />PHONE#2 <br />En. <br />BOS DISTRICT <br />LOCATION CODE <br />IS Y2,00-4$\ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR, <br />C�) tit -„rim CHECK If BILLING ADDRESS <br />U <br />BUSINESS NAME <br />PHONE# E'er. <br />HOME Or MAILING ADDRESS <br />'FAX # <br />CITY STATE 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard S ATE and FEDER laws. ] r1 l <br />APPLICANT'S SIGNATURE: DATE: 1 I O Z t t� ��CAeF�/Y�MppE//N��T <br />PROPERTY/ BUSINESS OWNER® OPERATOR /MANAGER'® OTHER AUTHORIZED AGENT❑ Ck-Jk�� RECENED <br />If APPLICANT is not the BILLING PARTY Proof Of authorization to sign is required Title��� n 0 2021 <br />OAR AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property t e <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siteMAGO[N COUNTY <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sameENViRDNMENTAL <br />provided to me or my representative. HEALTH DEPARTMENT <br />TYPE OF SERVICE REQUESTED: <br />owwhip 1 CVn <br />wf Otho / <br />COMMENTS: <br />ACCEPTED BY:Lau <br />j%I <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: Tl'tn' 4i <br />Date Service Completed l (if already completed): <br />EMPLOYEE #: <br />SERVICE CODE: <br />(JI ' <br />DATE: <br />PIE: f 1 a02 <br />Fee Amount: ' G <br />Amount Paid <br />¢i / S Z — <br />Payment Date <br />U <br />3 p 2 - <br />Payment <br />Payment Type <br />Invoice # <br />ck # 3 5 p <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED II/1712003 v 14-3291 <br />