Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> U ` C <br /> FACILITY NAME <br /> SITE ADDRESS tC c'-�e--c-Qve,o L�y � <br /> SVeet N¢mlNr Diroetbn Stro¢t Name Ci L Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) �2Fd/1.f SC 1 <br /> 'T" <br /> SGest NumOer StreetName <br /> CITY <br /> \ •�tYAOV-1 STATE <br /> n ZIP['+ a.._ <br /> PHONE#1 Exr' APN# LAND USE APPLICATION If <br /> PHONE#2 Ea. DOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR __ <br /> o CHECK If BIWNG ADDRESS <br /> BUSINESS NAME .�— 1 (4t.442-- Au-42- <br /> ONE# E*T• <br /> 2 2 <br /> HOME Or MAILING ADDRESS FAX If <br /> CITY r STATE LP <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 farm. <br /> 1 also certify that I have prepared this applicati doh t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , ATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: 202 <br /> 'a20 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTH ER ALTHORIZED AG ENT •� <br /> I,fAPPLICANT is not rhe BILLING PARTY.proof of authorization to sign is required Title <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 environmenta11 ''iee assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t!seQYAMa.it.i;. <br /> provided to me or my representative. R ••r=1. �I <br /> TYPE OF SERVICE REQUESTED: �,(,(.(,� <br /> COMMENTS: 2020 <br /> SARI U0AQUI <br /> Ro <br /> M lDEP�4 At <br /> NT <br /> ACCEPTED BY: EMPLOYEE 47 2) 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: U Q DATE: <br /> Date Service Comple d (If already completad): SERVICE CODE: c� rLl PIE: <br /> Fee Amount Amount Paid T�6•()� Payment Date .2-7 <br /> Payment Type 6 5G� Invoice# Check# j 7 3L�) Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />