Laserfiche WebLink
• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> MW <br /> sg � <br /> OWNER/OPERATOR p I� �7 I <br /> O <br /> Z Vf r ILL l ` 02� <br /> FACIUTYCHECK If BILLING ADDRESS <br /> SITE ADDRESS t �1�G.� � . JI c <br /> Street Number Direction l_ 1 Street Name ✓ Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Differe t from Site Address) <br /> Ode 4— A Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex*. APN# LAND USE APPLICATION# <br /> ( 2-(,P9 - o02- s-- <br /> PHONE#2 Ezv. BOS DISTRICT LocnnoN CODE <br /> clog) tv — S <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RErUESTO bl- 1 <br /> l m I } O^�.'- CHECK if BILLING ADDRESS <br /> 1 LJ� PHONE# E'IT• <br /> Bus)'T NATE- 6_ — U 2S <br /> HOME or MAILINr-ADDRESS FAX# <br /> v stn tJi N t ) <br /> CITY G�.{- STATE 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 Codex,Standards ATE an FEDERAL laws. ' 1 ' <br /> APPLICANT'S SIGNATU�R(/E: DATE: III Igo <br /> PROPERTY/BUSINESS OWNER VJ PE TOR/MANAGER ❑ ER AUTHORIZED AGENT❑ <br /> IfAPPLICANr is not the / mG PAR proof ofautko tion 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 i3 available and at the same time it Is <br /> provided to me or my representative. el re <br /> TYPE OF SERVICE REQUESTED: -food vehl(✓e `,OytDvt, �J cN <br /> COMMENTS: E� <br /> O'J <br /> 03 2020 <br /> rV <br /> N VIROQNINCOijN <br /> EALTy pE ANO NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L'll lJ EMPLOYEE#: DATE: Z, <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: I� <br /> Fee Amount: + 1cq 2 .Do Amount Paid 5a Payment Date 113 2 p <br /> Payment Type wypInvoice# Check# Received By: <br /> EHD 48-02-025 I I U g l M 33 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />