Laserfiche WebLink
SAN JOAQUI. _`OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e�obaT' s 590081 a49 <br /> OWNER/OPERATOR <br /> T14UA'N 100 CHECK If BILLING ADDRESS <br /> FACILITY NAME K t�� T�:7iu I-C "/ <br /> SITE ADDRESS LI "3 Pact t C>��S kki e CT- <br /> ES <br /> rQ re�umber Direction t' rest Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 40 J Street Number Street Name <br /> CITY /�A 1 STATE /_ ZIP �� O <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z5 — <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ��S Uy� CHECK If BILLING ADDRESS El <br /> BUSINESS NAMEPHONE# EXT. <br /> TV i�n�,ucti;� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP 9 Cj Z f <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERA, 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: REC <br /> a©fi h u a✓� D7 D�= C yc�Lc-o o . co.� -�1cY 0 8 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIwi=ALTHDEPARTMENT <br /> ACCEPTED BY: S • b a I I W h 1'1 EMPLOYEE#: DATE: ' O _ 8_ / <br /> ASSIGNED TO: M• F I O h r C h to t Z EMPLOYEE#: DATE: 0 <br /> Date Service Completed (if already Completed): SERVICE CODE: SZ � PIE ( �O <br /> Fee Amount: L� 5� OO Amount Paid x -- Payment Date l D <br /> Payment Typ Invoice# ChecLC# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />