Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> IType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' 'Fa ool I QQ-92a5 <br /> OWNER/OPERATOR <br /> n � --2, —7 SIL„ ,C CHECK If BILLING ADDRESS <br /> FACILITY NAME /� <br /> w 'TH L <br /> SITE ADDRESS W MAQcIA LN SU xTtr ASTUCK"7'ON C( V"�? Iei <br /> 261 ZI Street Number I Direction I Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /C/ /� �E°l JO$L Prt.��� ®� <br /> Street Number Street Name <br /> CITY 71f STATE A ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> (20q) 63�1 - 39 66 flu m 1 o <br /> PHONE#2 Exr. BOS DISTRICT LOCATION DE <br /> --• CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 6i/4 CHECK If BILLING ADDRESStff <br /> BUSINESS NAME ,} ��>> PHONE# Exr, <br /> 7r' 8 iv c. 'M �o U(W) 7A ISCE fZ2Z A 2601 <br /> HOME or MAILING ADDRESS FAX# <br /> O y <br /> CITY STATE (, n 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 <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: �rrqq" L DATE: 1 l 22 o;? 2-o 2c) <br /> /PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER IN OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sigh 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 sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UM W\' <br /> COMMENTS: �ff til <br /> rr11nArr'' ��( � <br /> l/vu�K V , 0 � pgt DEC 0 2 2020 <br /> SAN JOAQufN C <br /> NFMTMR EPgRT EENT <br /> ACCEPTED BY: EMPLOYEE M DATE: II,?V <br /> ASSIGNED TO: DO 0 EMPLOYEE M DATE: <br /> Date Service Completed (if already ompleted): SERVICE CODE: R9 l PIE: NO <br /> Fee Amount: G : � I Amount Paid Payment Date J -2-(-)-4r2-0 <br /> Payment Type "J -invoice Check# itoZJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�05�°�5S <br />