COMPLIANCE INFO 2004 - 2012 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI;ARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP HECEIVEp S _7 35 OWNER/ OPERATOR SAN JOAQUIN COUNTY ENVIRONMENTAL CHECK If BILLING ADDRESS FACILITY NAME DEPARTMENT SITE ADDRESS /hi v E p v 'V"t' DATE: 5 2a D I"F L L 1 1q [ Street Number Direction DATE: _5 - Street Name SERVICE CODE: Cf Zi Code Different from Site Address) HOME or MAILING ADDRESS-- 3 1 �i� Amount Paid 31S _ Payment Date /(If ( '-A`-//tel _\ '� \--- C Street Number v' Street Name CITY Check # (0-7 STATE ZIP T5 3 3� PHONE #1APN (c ) :5-11T3771 # 20 8-- Zoo -. o LAND USE APPLICATION # z- PHONE #2 ExT• IZvCI) rho - 7o -9-L SOS DISTRICTLOCA-n 15- CODE CONTRACTOR It SERVICE REQUESTOR REQUESTOR C/ / —7 J /SQ CHECK If BILLING ADDRESS 1141- J k/ f/�� BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAx # l ) CITY STATE ZIP 7Wj—'-s 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 PROPERTY/ BUSINESS OWNER ❑ y✓ ti �� DATE: —2— o OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If `1 PPLICANT 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 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 Ine or my representative. TYPE OF SERVICE REQUESTED: �� �— �� I I PAY COMMENTS: HECEIVEp MAY 2 0 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: /hi v E p EMPLOYEE #: .2 � DATE: 5 2a D ASSIGNED TO: L L EMPLOYEE #: Z,�,-7O DATE: _5 - Date Date Service Completed (if already completed): SERVICE CODE: P i E: Fee Amount: 3 1 �i� Amount Paid 31S _ Payment Date Payment Type v' Invoice # Check # (0-7 Received By: Llt,, EHD 48-02-025 SR FORM (Golden Ro REVISED 11/17/2003