COMPLIANCE INFO 2003 - 2007 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHyEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID It COMMENTS: SERVICE REQUEST # C7(,5 Sf JAN 1112007 SAN UNTY ENVIIRONMEJAQUIN NTAL HEALTH DEPARTMENT ! G L. L V 4F-- Shoo 14 `r 4 SS - S'OWNER . DATE: ASSIGNED TO: U O nI FL- tk & EMPLOYEE M F,31-7 OWNER / OPERATOR DATE: / / tl / D'7 [�2-3 CHECK If BILLING ADDRESS FACtLRY NAME SERVICE CODE: SITE ADDRESS 2132 Fee Amount: 5ROJ416N 131s-205- SZOSStreet StreetNumber Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # RLt3 i= I Received By. Street Number Street Name CITY STATE ZIP PHONE #1 EXT' APN If LAND USE APPLICATION # (Z�ti,4�(6 G28Z (73 -3s PHONE #2T' BOS DISTRICT ! LOCATION CODE CONTRACTOR / SERVICE REQUESTOR//�� d.{, ' CHECK If BUSINESS NAME h 161 HOME Or MAILING ADDRESS FAX# tin /�?- - '21 -:�-2 '-�- 1 (2a7 ) N6,j-YVE CITY STATE „—ZIPS Ear. BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: z j ZLI�I_ DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L'7 ! C A If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: us7-W-Icr)"F-L l RECEIVED COMMENTS: JAN 1112007 SAN UNTY ENVIIRONMEJAQUIN NTAL HEALTH DEPARTMENT ACCEPTED BY: G L. L V 4F-- EMPLOYEE M C) 3 ?a DATE: ASSIGNED TO: U O nI FL- tk & EMPLOYEE M F,31-7 DATE: / / tl / D'7 [�2-3 Date Service Completed (if already completed): SERVICE CODE: PIE: Op Fee Amount: a�'S', tTv Amount Paid �L?S, 01D Payment Date /9 7 Payment Type ✓ Invoice # Check # RLt3 i= I Received By. EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden 2�Q))