Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rA mot q n Sk a'� 1�- <br /> OWNER/ PERATOR <br /> CHECK if BILLING ADDRESS <br /> v/S5 &AVCDP-AA <br /> FACILITY NAME <br /> A Yi""' G <br /> SITE ADDRESS t7Ki/t't(J� S) STcXK TO /Says <br /> 5'O Street Number I Direction Street Name CI ZI Coda <br /> HOME Or MrAIILING ADDRESS (If Different from Site Address) q 1 r7 JD'�J � �/�J U <br /> K- ✓�2 tVA Street Number �J Strael Name <br /> CITY -0T� �7ATE ZIPM(Q �7S/ <br /> PHONE#t r V EXT. APN# LAND USE APPLICATION# J <br /> (So) 331- 9066 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR �1 <br /> vS I \•AV A 4 CHECK if BILLING ADDRESS <br /> BUSINESS NAME , �/f I PHONE# EXT• <br /> 7 <br /> A A A v Sri 066 <br /> HOME or MAILING ADDRESS FAX# <br /> '7 ;FLID&Z WA ( ) <br /> CITY ztlOV / STATE 4 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandardsZSTA andFEDE s. <br /> APPLICANT'S SIGNATURE: DATE: 12 /12.1221 <br /> PROPERTY/BUSINESS OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPIICANT it not the BILL/NGPARTY 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 same time it is <br /> provided to me or my representative. As MENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: — <br /> L��Lvl�e FEB 2 2 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 22 Z� <br /> ASSIGNEDTO: MAUL <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: D I E: <br /> Fee Amount: J r Amount Paid �- Z Payment Date ;?--/2 �lLv 2--1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />