Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S-VAV ti'i nqo -��)Zo ' dFooglV31S <br /> OWNER/OPERATOR�M. I(4��- /'yA�-I}V <br /> CHECK If BILLINGA00RESSO <br /> FACILITY NAME WfaINEMPO e JApf ., � <br /> SITE <br /> ADDRESS Eo) <br /> Ll 1`-4pP-44 l-Ar-� sn�� gszlg <br /> Streel Number Direction Street Name cityZI Cotle <br /> NOME Or MAILING ADDRESS (If Different from Site Address) 1 G <br /> Street Number Street Name <br /> CrrYSiv"i1 _ I CA — L3 ZAAJ <br /> STATE ZIP <br /> PHONE#I ExT' APN# LAND USE APPLICATION# <br /> (Zo5 ) 513-�H�1 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 SIGNATURE: YG_/� DATE: ?jam <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICAAT is Not the BILL/NG 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RMEIVED <br /> JAN 3 0 7023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � EMPLOYEE#: I DATE: I JU Z <br /> ASSIGNED TO: I iA �X EMPLOYEE#: CST DATE: I 76 '�J <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P1 E: KPO <br /> Fee Amount: D – 77TAmount Paid Payment Date I 3u ;L ?) <br /> Payment Type 1 S Invoice# C k# 5- g(o� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />