Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property tt FACILITY ID# ERVICE REQUEST# <br /> OWNER/OPERATOR LIC, <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _..YA.L.iti(A`7 !1 (Z g 1 <br /> SITE ADDRESS C [J(�RGUNA1NLii- l-VL * gSZID <br /> Street Number Dir on S et Name Zip Code <br /> f� t <br /> HOME Or MAILING ADDRESS (If Different from Site Address) '555tom <br /> 0 t-1, ow mti -A\)L S-C3O <br /> Street Number Name <br /> CITYmow\O N 1 STATE ZIPS3� <br /> T Gik <br /> PHONE#1 EaT. APN Is LAND USE APPLICATION# <br /> (51o ) -ig23393 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> 1 I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> HOME or MAILING ADDRESS FAx# <br /> ( 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: �21 cn ��� DATE: I2022_ <br /> tLy � <br /> PROPERTI'/BUSINESSOWNERtB' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPUC.AAT is not the BILLING PARTSproof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: <br /> JUL /Z 2021 <br /> SAN JOAQUIN COU <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE III: F- DATE: 12. ZL <br /> Date Service Completed (if already c mpleted): SERVICE CODE: O Z I PIE: I Z <br /> Fee Amount: 1 Amount Pai �Jlo Payment Date Z� <br /> Payment Type _ Invoice# Check# / � � Received By: <br /> / CC� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />