COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

JAN JOAQUIN UOUN'IY ENV1RONNIEN'IAL HEALHLEYAR11VILN1 SERVICE REQUEST Type of Business or Property FACILITY ID# ]TSERVICE REQUEST# Fts a nt t _ 3ko OWNER I OPERATOR 15 t CHON&I TUN / C� 6FV4�T0IQ` CHECK If BILLINGADORESS� Facam NAME�>Omu'- S jo6nutCTS SITE ADDRESS 101 FIA WE--I I(.TH- -5-Tl2�-T -�12A�.y C.R `' 5 3 7k,- Street k;Sheet Number Direction Street Name city Zio Code HOME or MAILING ADDRESS (If Different from Site Address) ig61 Y-: NeDy PL- Street Number Sheet Name STATE ZIP Clrr -TPACy r� 9")7 PHONE#11 EXT' APN# LAND USE APPLICATION# 15ro2 ) lotD- 14{`i PHONE#2T BOS DISTRICT LOCA710NCODE CONTRACTOR/ SERVICE REQUESTOR R.EQUESTOR C{-f CHECK if BILLING ADDRESS❑ T� N a�l/L- BUSINESS NAME PHONE# Ext' HOME or MAILING ADDRESS ' n FAx# T ( ) CITY S I p4- STATE Zip 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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STAT EDERAL laws. APPLICANT'S SIGNATURE: _ DATE: 3 1 yao tog PROPERTY/BUSINESS OWNER❑ "'A6 ORATOR/MANAGER OTHER AUTHORIZED AGENT❑ IfAPPLICANT is notate BLLLLVGPARTP proo ojauthorization 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 environmental/site 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. n TYPE OF SERVICE REQUESTED: /-� d i4C-° I L. / L A-ej COMMENTS: AfPC.IGf W( I..,lu. 41IQNlOt OIC C ars pwaa* Pi5 (°c 9s Ie L)a .4�O {z nJ t S F-r S GhE E-,9 t-C. Cc—r- MNOpQU1MENSN- ACCEPTED BY: O L I V E � _. EMPLOYEE#: [)J? DATE: P� ASSIGNED TO: 0�" /��l� EMPLOYEE#: 7 DATE: 2'e�) QK Date Service Completed (if already Completed): SERVICE CODE: J/Z P1 Fee Amount: �G� Amount Paid '0-9 � Payment Date Payment Type Invoice# Check# 335" Received By: EHD 48-02-025 SR FORM( ofdenRodj ' REVISED 11/17/2003