Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SERVICE REQUEST / /<' 0 5� Y941,7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SROOS75 4q <br /> OWNER/OPERATOR TMDA Ni-,T 4 N-ANDYA L— pSSID <br /> UA'i tS LILC CHECK If BILLING ADDRESS <br /> FACILITY NAME J4yDCRfl$ADT &ATL <br /> LUM SITE ADDRESS (2 S, 4e¢,t' M-o �C:. ,ST a -1'.5 35 <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from SiteAddress) <br /> � <br /> *O r�\ULfAOLPrNV DP,. Street Number Street Name <br /> CITY ^ ' STATE ZIP <br /> GA 4 52 6 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t°125-- 169 u- 2t).5 9 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR /��SERVICE REQUESTOR <br /> REQUESTOR "VA N k2 & N A^)DYA L IrC a� 00ATCS LTL CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# ExT. <br /> R OECABAII cfr-rz <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 11�2D`202-3 <br /> PROPERTY/BUSINESS OWNER L 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 �QVId_ ed t0 me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C O ir\S u 14-CAA-io-vL ceive <br /> COMMENTS: DEC 2 0 2023 <br /> SAN JOAQUIN COENVIROIVM, U <br /> HEALTH <br /> D PART NT <br /> ACCEPTED BY: S. EMPLOYEE#: DATE: Oti!�1 _ , '1 3 <br /> ASSIGNED TO: G. FOA ryt EMPLOYEE#: DATE: / O� <br /> Date Service Completed (if already c pleted): SERVICE CODE: PIE: <br /> 1; <br /> Fee Amount: Amount Paid /6,2. nr—) Payment Date 23 <br /> Payment Type �- Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> r <br />