Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR CHECK If BILLING ADDRESS❑ <br /> t <br /> FACILITY NAME <br /> C4 r, <br /> I� 1 i <br /> SITE ADDRESS �.� `I � C�I�a��V L <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or Ij(IAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYM STAVE ZIP ^� <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# (� <br /> (HJT b 0 7, 14-1, <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) ✓✓ 2-3 I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AI f ^ r / 1 <br /> BUSINESS NAMECHECK if BILLING ADDRESS❑ <br /> _ / / T` 1 ` 4(J PHONE EXT. <br /> L11 CA, <br /> 2 <br /> HOME or MAIL GA RESS ^^^ V FAx# <br /> CITY 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,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: f na 1 t DATE: ( f Z J Z <br /> - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If 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 provid to me or my <br /> representative. /4 y <br /> TYPE OF SERVICE REQUESTED: C`1 V1C e G Q x,00 e I( CE <br /> COMMENTS: <br /> N qQV/ <br /> H�CTyoEpN IN ry <br /> FI yT <br /> ACCEPTED BY:"t�)Y 't CEMPLOYEE#: DATE:CA c) 1 2--3 <br /> ASSIGNED TO: Y—C.16eC,nYI\ L EMPLOYEE#: DATE: Ct S 12� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ,6W2- <br /> Fee Amount: Q(j Amount Paid �LO it Payment Date <br /> Payment Type n Invoice# C (-v 2Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />