Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR D 3D a. <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ii C CX a M q <br /> FACILITY NAME <br /> �GIYi � C PcAbla <br /> SITE ADDRESS } �+ /J =DII..11.. <br /> C12 /\,�� --� �{.� GIS2—D�Street Number Street Name MIXl 21 Code <br /> HOME or MAILING?ADDRESS (if DifferentfromSite Address) <br /> Z�1(IC r 'CO)11 e 1 5A rt- 6.0 Number Street Name <br /> CITY STATE zip Fl�� {olz til r� Sficx�k to n g520s <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( . ) -L-2 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> n cA CHECK if BILLING ADDRESS <br /> BUSINESS NAME!$ PHONE# EXT. <br /> V a C S aL IG f'C 4 G 2 z <br /> HOME or MAILING ADDRESSI26 E Chi el <br /> S-` dee (Ax# } <br /> CITY -C�Ck C 1 t 0C � ,Q ` STATE zip 5 <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: t)Gm I- 'f DATE: 10 l o ti f Zo Z_� <br /> PROPFRTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORizED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required 741te <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 tame time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: {-0QA C'DgA AJL (�j" � <br /> COMMENTS: r <br /> of 2021 <br /> ACCEPTED BY: tI Y EMPLOYEE#: DATE; 'My f 2 I <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: rl <br /> Fee Amount: 7 Amount Paid Payment Date h V <br /> 421 <br /> Payment Type 4 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />