Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'FAG(D(DCD,4 24 GZB(o(0(P <br /> OWNER/OPER�ITOR <br /> l CHECK If BILLING ADDRESS <br /> FACILITY NAME �"7 If Ci� CL�TI //7--A i? <br /> SITE ADDRESS���ji L ref �C od'( (w /r2�42 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �}�V� PHONE# EXT. <br /> ( Z�) ��' � 3 <br /> HOME or MAILING ADDRESS J, / FAX# <br /> ( ) <br /> CITY / 690 STATE ZIP 7.j-2 �/� EMAIL <br /> BILLING ACKNOWLEDGEMENT: J <br /> 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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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 F RAL, <br /> APPLICANT'S SIGNATURE: —,---- DATE: 2-1123 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: Q�(J�- � �v ` r0-� RFCFIVFn <br /> COMMENTS: <br /> APR 2 7 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1�I�, C EMPLOYEE#: DATE: 2'�L,Z'2? <br /> ASSIGNED TO: `y EMPLOYEE#: DATE: Lt —Z� _12 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: G <br /> Fee Amount: (�6 Amount Paid ,� 1� Payment Date 2 Z� <br /> Payment Type V It S A- Invoice# Cock# L11192— 6 eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />