Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# , SERVICE REQUEST <br /> ca/J 1.5 l �G� gnn ' <br /> OWNER/OPERATOR /J �/ �]✓ ( /%l M� CHECK If BILLING ADDRESS <br /> FACILITY NAME I'C�I'� Wl2zr J <br /> n <br /> SITE ADDRESS <br /> Street Number I Direction /L.S�ti/ WI'Z treet Name Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> / L J /`� / !4//' S/" Street Number /u Street Name <br /> CITY _ STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) ��— x(57/— 7'97'5 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> c ) - Ze X 2-(g8 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ ,/ <br /> �,�yJ--/DO� - CHECK If BILLING ADDRESS <br /> BUSINESS NAME „ PHONE# EXT, <br /> l�r S S 0 - �- ;>'K . <br /> HOME or MAILING ADDRESS FAX# <br /> / 0IVA ( ) <br /> CITY ' v�� �0 STATE ZIP ins <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER El- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑�L/�il/ � <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: N S C—7-/()/ ,4 <br /> COMMENTS: RECEIVED <br /> MAN ! 5 2019 <br /> SAN JOAQUIN COUNTY <br /> Ewp.NVIRONME <br /> ACCEPTED BY: EMPLOYEE#: DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d(Q -- -FP/E: 16C a <br /> Fee Amount: j `�' Amount Paid (S D D Payment Date 3 25 <br /> Payment Type Invoice# Check# l b4q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />