Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />PHONE# Ems• <br />HOME or MAILING ADDRESS <br />51113 E. R to YLyi <br />#% <br />90"00 15-9 Z(P <br />OWNER / OPERATOR <br />❑ <br />�M(JiT E ZrRPWS,!L 1114C <br />CHECK if BILLING ADDRESS <br />FAculTv_N7 L LIQ. �e o�,d voci� <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already Com ed): <br />�'� )/(�,"'ey � <br />!7 <br />P / E: 1 O <br />Fee Amount: � <br />AASITEADDRESS <br />Jd 3 r Street Number <br />Direllon <br />Street Name <br />Z <br />city <br />ZIP Code <br />HOME or <br />r MAILIN`G�.(ADDfR,ESS (If Different from Site Address) <br />Check # <br />Received By: <br />J / <br />5S6 U, / P le a/,. Street Number <br />Street Name <br />CITYCra ` / STATE 02 <br />/ r <br />PHONE#i E <br />c��W) 368-3Li9S <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />(X)) 327- 6171 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />12 J s <br />J �L� C S. <br />V /, ` I CHECK If BILLING ADDRESS <br />N /1 <br />BUSINESS NAME <br />COMMENTS: n <br />(J VRolym <br />PHONE# Ems• <br />HOME or MAILING ADDRESS <br />51113 E. R to YLyi <br />#% <br />FAX# <br />c ) <br />CITYZ <br />r.9/I STATE ZIP O <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 nd that the work to be performed will be done in accordance with all SAN JoAQUIN <br />COUNTY Ordinance Codes, Standards, STATE atffl FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />211 M. - <br />If APPLICANT is not the BILLING PARTY proof of authorization 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. PAYAmai- e <br />TYPE OF SERVICE REQUESTED: <br />` t}Vl,�wl <br />ECF <br />COMMENTS: n <br />(J VRolym <br />SEP Z 6 2022 <br />SAN J(>AUIV COU" <br />ENrAL <br />HE117y DEPgRTMENT <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: <br />71a <br />Z�7 <br />ASSIGNEDTO: VIA 1� <br />EMPLOYEE <br />DATE: <br />Date Service Completed (if already Com ed): <br />SERVICE CODE: O(/1 I <br />P / E: 1 O <br />Fee Amount: � <br />Amount Paid <br />Payment Date <br />Gr 2 <br />Z <br />Payment Type 1 <br />Invoice # <br />Check # <br />Received By: <br />L� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/20032 <br />