Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />712 f- F. <br />FACILITY ID # c, SERVICE REQUEST # <br />spOONW2 <br />OWNER/OPERATOR , / CHECK if BILLING ADDRESS CA 0 / g,egz - VeYei- <br />FACILITY NAME <br /> <br />Street Number Direction <br />SITE ADDRESS <br />Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />,3 6 <br />Street Number <br />/6--- y 2 <br />Street Name <br />CITY <br />-S.-7-D C77)/i3 <br />STATE (34 ZIP <br />gN5- PZ/S. <br />PHONE #1 Ex-r. <br />VioP g..CO — APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />7224k, C() ?27) C ,17) <br />, <br />CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME 2(..,() c &well 74 F e0/0.S0 44 /2 PH,crElt <br />Q. ) Q <br />EXT. do ,,,,,z <br />HOME or MAILING ADDRESS 2 ,3.,_zo e/s,z..a.s/..;4) FAX # <br />( ) <br />CITY '-7e, E-S-- <br />STATE <br />C4- <br />ZIP q ,s— 3z)..5. EMAIL /22e/c.0717di&Oiee/g find/ <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 />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 />cA-P7 <br />PROPERTY! BUSINESS OWNER 0 OPERAT R / MANAGER EU OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />OS- if- 7L6Z3 <br />ee077s-d/AV ..,,cS71/7/7D <br />Tit e <br />APPLICANT'S SIGNATURE: (iy-ta earth <br />DATE: <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 proAed to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: 10 () P [ °WI '1/t/ CAL <br />...iv i <br />fteCeilf E'D <br />COMMENTS: MAY / <br />SAN JOAQ. <br />1 <br />2023 <br />ii,,9k/V/Rolvji. COCA/71,, <br />"LTH DEiongElvrAL ARNE.Air <br />ACCEPTED BY: Alit <br />\._ <br />EMPLOYEE #: DATE: if 23 <br />ASSIGNED TO: <br />',,/ <br />kii.) EMPLOYEE #: DATE: <br />J <br />Date Service Completed (if alr dy completed): SERVICE CODE: 52_5 P/E: / 1,0 I <br />Fee Amount: 14-6g Amount Pai 44 5-. Dr) Payment Date <br />Payment Type 0*. Invoice # Check # 45-1/63s-- Recei ed By:06----- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23