Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Ir A W /89 '7m S Ovb9682�+ <br /> OWNER / OPERATOR <br /> I n CHECK If BILLING ADDRESS ❑ <br /> ` nI <br /> FACILITY NAME A , ` wti' <br /> P -fl) SP eAr +A ) 's 1 i4 Z7 A / ' ' n i <br /> V � � l <br /> SITE ADDRESS ) -[' Q � � ( -� Aoe ,. :s uotP L-0TU <br /> Street Number Direction ) U Y Street Name city Zi Cotle <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) J VV ) r��1e S� -}- <br /> reet Number �' ' Street Name ` 1 ' <br /> CITY C� ,rJ STATE ZIP <br /> PHONE # 'I Exr, APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR W J� <br /> L 1 1 /L i , qI / CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT . <br /> 2YD �5 W1111d 626 CklAaM U151W ( ) <br /> HOME or MAIL ' "' ^ A ^ r, or: c-% c% I I I FAX # <br /> IL <br /> 61S Y2 <br /> �n / ' .gyp , <br /> CITY $TATE ZIPSj0 2 , EMAIL j 31 <br /> & yn (, ; - ap nn <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 a F DEL- I ws . <br /> APPLICANT ' S SIGNATURE : DAiU141VTE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MA GER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, , oof 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 tWe or my <br /> representative . lye <br /> TYPE OF SERVICE REQUESTED ' r C� • <br /> COMMENTS . f <br /> SAN � � 3 Zoe <br /> HSL V/RONAQ C <br /> f, O <br /> TNOFpgN7%44 <br /> ON <br /> ENT <br /> ACCEPTED BY : EMPLOYEE # : 9� � s DATE : <br /> ASSIGNED TO . Vl c1( �k' EMPLOYEE # : wZ � '� DATE : �, �/ `� / Z 0, 2 <br /> Date Service Completed ( if already completed ) . SERVICE CODE : ' T <br /> I E : /& o 2 <br /> Fee Amount . 0/T6 � Amount Paid Payment Date <br /> Payment Type � �_ , Invoice # Check # Received By . <br /> EHD 48 -02 -025 SR FORM ( Golden Rod ) <br /> 03/22 /23 <br />