Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST �'P DSy'2c111 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 10 OL <br /> SITE ADDRESS <br /> Street Number I Direction Street Name city Zip Code <br /> HOME oriiMAILING ADDRESS (If Different from Site Address) <br /> Vil <br /> i ^ <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> or /I- l Z <br /> PHONE#1 / EXT. APN# LAND USE APPLICATION# <br /> (MCI) V�s- <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR i oa CHECK If BILLING ADDRESS❑ <br /> l C' G.l l�Q� <br /> BUSINESS NAME PHONE# EXT. <br /> I e C c '-!�-f I q 5 - S 3 81 <br /> HOME or MAILING DD ESS FAX# <br /> CIT GC t STA? ZIP Z t EMAIL <br /> H <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. <br /> APPLICANT'S SIGNATURE: DATE: <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 ptAVNr@V.,Q my <br /> representative. �► <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �/ `/���/ L�/� SAN 1024 <br /> O&V M <br /> �ir <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: `• <br /> ASSIGNED TO: EMPLOYEE#: DATE: 4Z 9 <br /> Date Service Completed (if already completed: SERVICE CODE: �, I O/E: ?r <br /> Fee Amount: Amount Paid I r) 2 <br /> • Payment Date /Z 1 2�J <br /> Payment Type Invoice# -"51 -qReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />