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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ndo r+ S'—Q�oo <br /> OWNER PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME � <br /> IDNA w <br /> SITE ADDRESS h -�y� <br /> 2 dt`tG�lmber Direction reef Name Cit Zi Code <br /> PHOM r AILING ADDRES V(if Differe from Sit d rgs) G( � � <br /> ICS Street Number Street Name <br /> Cl STATE ZIP <br /> PHONE#1 rn r^ ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> I �W(vl <br /> CONTRACT R / SER CE REQUESTOR <br /> REQUESTOR l(l-0l(KfAA1?1A <br /> n CHECK if BILLING ADDRESS <br /> BUSINESS NAME I�� PHON EXT. <br /> q65-gZ C� <br /> HOME MAILING AD RES I �{ FAX# <br /> CITYZIF o-I EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or- ['-7business 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, TATE and FEDERAL laws. 22 <br /> APPLICANT'S SIGNATURE: DATE; UCS ZOZ3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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. p <br /> TYPE OF SERVICE REQUESTED: '. _ _ 1�i R� T <br /> COMMENTS: AtIG <br /> 23 ?023 <br /> pQ,UII,y,��_ M <br /> ftiii�4 ��NT7y <br /> ACCEPTED BY: J 1 EMPLOYEE#: DATE: ,;2 1a <br /> ASSIGNED TO: EMPLOYEE#: DATE: !,;2 113 <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: C3 <br /> Fee Amount: G K, Amount Paid ��" Payment Date 2 3 2 <br /> Payment Type Invoice# �Mec cl' p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />