Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> C 0 er-L <br /> FACILITY NAIR <br /> l VT <br /> SITE ADDRESS S 7 (� W .D Y - ' _ I�'� J r p V a S rf S z o <br /> Street Number I Direction Street Name city21 Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> b Q 1 Street Number Street Name <br /> CITY < STAT Z5 Z O <br /> PHONE#1 ENT. APN# LAND USE APPLICATION# <br /> (209 ) -500 q 7 <br /> PHONE#2 ENi. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A M <br /> D t CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ENT• <br /> gr t1 I Ce--r: a o ' 30 9 <br /> HOME or MAILING ADDRESS FAx# <br /> O N ; o W l 1 <br /> CITY STATE ZIP 252-05 <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 t11at 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-/jy) () (fi%C G COI 1'{ <br /> ' P-VYe- i - DATE: 619 I.LT2 Z- <br /> PROPERTY/BUSINESS OWNS —DOPE�RATORR//MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIAUT isnot the BILLING PARTS'proofofauthorizaBon to sign is required Title PAYMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locatdaE VED <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" a i? 2022 <br /> provided to me or my representative. <br /> J ENVIRONM NTA, <br /> TYPE OF SERVICE REQUESTED: NEALrx Q¢PA amsur <br /> COMMENTS: )/ <br /> 71;2- <br /> ACCEPTED Y: EMPLOYEE#: Z I �f DATE: +L <br /> ASSIGNED TO: LIr. EMPLOYEE#: ( TC DATE: 1 '�'1 y 2� <br /> Date Service Com ed (if already completed): SERVICE CODE: v PIE: v 2— <br /> Fee Amount: ✓ Amount Paid Payment Date v0 Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />