Laserfiche WebLink
1 <br /> SAN JOAQUIN COUNTY EN` IRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Cas S n to fo rte- LA S\ZC) 0 <br /> OWNER / OPERATOR w) h1 Ct'� c / / u S (! � L 1 11 CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME // / ( / <br /> (S� Y �er / frc�ct ; �c <br /> SITE ADDRESS <br /> 10,qc ,lic 9ve <br /> . <br /> Street N mber Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Ireat Name <br /> CIrY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPUCATION # <br /> c5io ) Z67 - 66 3 <br /> PHONE #2 Em BOIS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /f �/f / CHECK ifBILUNGADDRESS <br /> IJ <br /> " I � Gd1 " / U t <br /> PHONE # / Exr' <br /> BUSINESS NAME 71 �� Coo <br /> ! s ;7 re C; ' C T c r � r L� <br /> 623 <br /> HOME or MAILING ADDRESS Fax # <br /> CITY /t � n 'I STATE G �j ZIP 9 rah <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 bille�� to me or my business as identified on this form . <br /> I also certify that I have'i prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Co i es, Standards, STATE and FEDERAL laws . j <br /> APPLICANT'S SIGN�ITURE : J f ,� ,1' DATE : _ 1 I l. 2 <br /> PROPERTY / BUSINESS 010 WER C9 OPERATOR / NIANAGER ❑ OTHER AUTHORIZED AGENT ❑ (a I Y, <br /> IJAPPLIfANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION : When applicable, 1, the owner or operator of the property located at the <br /> above site address , breby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN , OAQUIN 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 : RECEIVED <br /> COMMENTS: /1 MAY 2 0 2021 <br /> Re1� � e� Le <br /> ,AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> : ILALTH DEPARTMENT <br /> ACCEPTED BY' �/)+ EMPLOYEE #: DATE: <br /> ASSIGNED TO : J EMPLOYEE #: DATE* <br /> Date Service Completed ( if already completed) : SERVICE CODE: C� G 1A 12 <br /> P l H : <br /> Fee Amount: LI e U Amount Paid Payment Date r, �,7 L <br /> Payment TypeInvoice # # 2 3 I Received By: <br /> Vol <br /> EHO 48-02-025 � � SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />