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2-0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y v <br /> r SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> +6( SROOS7431 <br /> OWNER/OPER TOR <br /> CHECK If BILLING ADDRESS❑ <br /> v V r <br /> FACILITY NAME /� <br /> S 4[� <br /> S E ADDRESS4- S IV � j� P ✓C <br /> 14 1 r ' 7 Street Number Direction Stlre`et(JN�ame Ci Zip Code <br /> HOM O�AILING ADDRESS f Different from Site Address) <br /> W Street NumberT Street Name <br /> CITYt- ` STATE ZIP152-- 3 <br /> iC <br /> P� E#t EXT. APN# IJLAND USE APPLICATION# <br /> ) <br /> PHONE#2 ExT. EMAIL —166S-DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> /p <br /> INESS NAME (� I PHONE# (� EXT. <br /> G.. lX G. X11 L' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �l ST,AT ZIP 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 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 FEDERAL laws. r <br /> APPLICANT'S SIGNATURE: —f � �/ �j<U DATE: I S Z0Z3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tille <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: {-� Recell <br /> COMMENTS: <br /> 'T u C K �a av' �d (-w n eA sAN�OV ,$ 2023 <br /> V IyW/RON/N COUNry <br /> EARTH pFP NT <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: i j_15 _2 2 <br /> ASSIGNED TO: EMPLOYEE#: ,1 g DATE: 11- 15 - o13 <br /> 11_ 1✓5 _ o1 3 <br /> Date Service Completed (if already completed): SERVICE CODE: O I P I IE.`/r /n O�1 <br /> Fee Amount: �'1 Amount Paid �� Payment Date /Sl lY pC <br /> Payment Type (a5z6 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) _. <br /> 03/22/23 - . <br />