Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CaTclzw/7 -b f. <br />SmoKe4hrot-t9 h _ bhp <br />S <br />OWNER/ OPERATOR <br />❑ <br />, tAWINAL D. Sc DI EI/ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />`Qi(E�/-FE/25 5m�(=ETkRtSvyN 3 t3•G2. <br />SITE ADDRESS <br />EMPLOYEE M W <br />FAX If <br />ASSIGNED TO: AA_ Q Q 5 <br />11 I W Cn12L ti AVG <br />EMPLOYEE #: 33 <br />Street Number <br />Direction <br />CITY 57a c.kT6 iL <br />Street Name <br />city <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Date $/-12-1 z <br />Payment Type C_KP.cI'-r/ <br />'I1 CA2 L7Zti /9 VE <br />Stroel Number <br />Street Name <br />CITY <br />7-0A-' <br />STATE ZIP <br />9T <br />691 95-263 <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />(7-M ) UZ-3 S/Vo <br />PHONE #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />V//�� J <br />6NO A_P L D _ Soti-�e <br />y,��� J FO— I��' <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />SmoKe4hrot-t9 h _ bhp <br />PHONE# <br />E.T. <br />151ZO-r(.IE0125 sa okE 7 -Hr 0 Z/ er H 3. R. a . <br />(w� <br />t,2-3 rt yo <br />HOME or MAILING ADDRESS <br />EMPLOYEE M W <br />FAX If <br />ASSIGNED TO: AA_ Q Q 5 <br />11 I W Cn12L ti AVG <br />EMPLOYEE #: 33 <br />( ) <br />Date Service Completed (if already completed): <br />CITY 57a c.kT6 iL <br />STATE CSQ <br />ZIP G/r203 <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 SIGNATUR �,.,( DATE: <br />PROPERTY/BUSINESS OWNE OPERATOR/MANAGER LJ Or R AUTHORIZED AGENT El <br />IfAPPLICANT is not the BILLING PARTY proof of auth tZation 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 is available and at the same time it is <br />provided to me or my representative. VAS <br />TYPE OF SERVICE REQUESTED: CO <br />y,��� J FO— I��' <br />COMMENTS: <br />A <br />06 <br />SmoKe4hrot-t9 h _ bhp <br />L1a ltioo . co 3,gv,/o 2021 <br />0 O <br />N4tTVIRQ/✓lNC U <br />ACCEPTED BY: - <br />EMPLOYEE M W <br />DATE: 8 Z' <br />�S� <br />ASSIGNED TO: AA_ Q Q 5 <br />EMPLOYEE #: 33 <br />DATE: <br />�/ZI <br />Date Service Completed (if already completed): <br />—/Z <br />SERVICE CODE; 06, , <br />I P 1 E: <br />lX <br />Fee Amount: <br />Amount Paid �5{ d <br />Payment Date $/-12-1 z <br />Payment Type C_KP.cI'-r/ <br />Invoice # <br />Check # 12 724_3 <br />Received By' <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />