Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ' " V �) S I� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME / /� /D / n n / ,� ^ /� 6 <br /> SITE ADDRESP �/ �f ' VA��v n t a �T <br /> get Number Direction ` c�v\ Str�d Cit Zi Code <br /> HOME or AI G ADDRESS (If Different from Site Address) <br /> (y ' )v�treet Number C ' Street Name <br /> CITY LSTATE ZIP c; <br /> PHONE#f ExT. APN# AND USE APPLICATION# <br /> (,�J 3 —9 7 66" C X15 zqc� ,L <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> I Lt <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <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 /> � / 2 <br /> APPLICANT'S SIGNATURE CtI' I DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO 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 provided t0 me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: RE <br /> COMMENTS: <br /> FES 13 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I•{MTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ` DATE: /L, t-2, 2 <br /> ASSIGNED TO: EMPLOYEE#: S DATE: <br /> Date Service C repleted (if already completed): SERVICE CODE: I PIE. C <br /> Fee Amount: 162Amount Paid �� Payment Date ` Is <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />