Laserfiche WebLink
I�of(03 c U3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �R(�(D b-+(T�11 <br /> OWNER/OPERATOR <br /> �/(�� CHECK If BILLING ADDRESS <br /> FACILITY NAME SUBWAY <br /> 'BW^f• SPN0\&J1C-H W l07dl <br /> SITE ADDRESS V/��] ///(���J VVV 1v, 9� D NTOV u <br /> Q rTE'YI7 . eT Direction Street Name Cit Zi Code <br /> HOME or MAILING <br /> nWADDRESS (if Different from Site Address) <br /> 10 -I� /( ee Street Number Street Name <br /> CITY LA04410 STATE �� ZIP V33o <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> "(3) 56 -6:'23 <br /> PHONE#2 EXT, EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR D Al, T i� u'\/� <br /> /'lt CHECK if BILLING ADDRESS <br /> BUSINESS NAME U�� \' f ��/ PH NE# 6-5.23En, <br /> J �� ) 5-9�- <br /> HOME or MAILING ADDRESS /U L.) O M A 91N FAX# <br /> ) <br /> CITY D STATE C Iq ZIP O EMAIL <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 or activity <br /> will be billed to me or my business as identifie on this form. <br /> also certify that I have prepared this applica n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE FEDERAL I2WS. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY I BUSINESS OWNER❑ OPO MAN GER ❑ OTHER AUTHORIZED AGENT ElIf APPLICANT IS not the BIL G 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 to me or my <br /> representative. E <br /> TYPE OF SERVICE REQUESTED: e hCl V) LE 01 �WheYS�l i 'VJ`D <br /> COMMENTS: J 0 4 2023 <br /> �RQN�CpLti lY <br /> EP NT <br /> ACCEPTED BY: ✓Y%Cti�YIE EMPLOYEE#: DATE: <br /> ASSIGNED TO: i ,IUSL� EMPLOYEE#: DATE: V4/ ZdZ <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E:/' m <br /> Fee Amount: I/o2 Amount Paid �2 Payment Date 7 23 <br /> Payment Type Invoice# c # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 S <br />