Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 RAS )IA s e cam <br /> OWNER/OPERATOR ///��� <br /> J� l I w�S� CHECK If BILLING ADDRESS <br /> FACILITY NAME 5K t" �vvv�CCC I�NNNS <br /> SITE ADDRESSl 9 1n/ yy Ma✓C to s�Ck 4-- '/ 5 2 a 7 <br /> Street Number Direction Street Name city Zip Code <br /> HOME OrMAIL�JJ,�,IG�tADDRESS (If Different from Site Address) IM� SCS"^✓ � r�L�f� ✓-- <br /> "1[� Li — Street Number Street Name <br /> CITYSTA ZIP <br /> L3I c_ 9r2 , <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> ('v)I) 21 0 — --T�-56 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 9 <br /> w-e S� CHECK if BILLING ADDRESS <br /> V1 <br /> BUSINESS NAME ` r e S1 PHONE# EXT. <br /> HOME Or MAILING ADDRESSI�S G"�H o✓-o�5 f FAX# <br /> CITY I STATE 04 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 or <br /> 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 FE AL laws. q <br /> APPLICANT'S SIGNATURE: ( DATE: <br /> PROPERTY/BUSINESS OWNER Ef OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ P" f C c o <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 <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> MAY 15 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: LOW <br /> / —0EMPLOYEE#: DATE: <br /> ASSIGNED TO: Vidal <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed: SERVICE CODE: I I E: <br /> Fee Amoun : Amount Paid l S� _ Payment Date 5/.L <br /> Payment Type G o� Invoice# Cbe'A# L J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />