COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Apr 24 14 02:02p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST P.1 Type of Business or Property FACILITY 1D # SERVICE REQUEST # L.1 isuop FAX# CITY STATE ZIP COMMENTS: �-, I^I� � OWNER / OPERATOR k x ' � / R / CHECK if B7LLNVf.' ADDRESS FACILITY NAM' EV` V DATE: S� ss % J� /0-04-0 1c q �'� c i cl `53 -7 Street Number Direct) )e Name C C de HOME orr7MAILING ADDRESS (If Different from Site Address) Invoice # ChecK if _ `-) O / / 6eCC.-! CNg 1-,1 f2/e K 2-A-) Street Number Stns Name CITY ixr� /1/r ' f' STATE C /4 75P /+ PHONE #1 APM LAND USE APPLICATION ZK ( 201) 43 y Dc?UD PHONE #2 FXT- (40,r) L-/Zo 2-07S Ge /l BOS DISTRICT Lo CATION CDDE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if g11.LING ADDRESS BUSINESS NAME PHONE # Ex -r' HOME or MAILING ADDRESS FAX# CITY 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, StandAardds, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: V �-r-' �C__ /C DATE: o PROPERTY/ BusiN Ess OWNER EJ"— OPERATOR(.MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICAN7' is not the RiLLI.NG PARrY. proof of authorization to sign is required rule AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 JOAQUITI COUNTY ENVIRONMENTAL FD ALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: BEGFIVED COMMENTS: �-, I^I� � APR 2 4 2014 ENVIRONMENTAL HEALTH PERMIT/SERVICES ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount (2-,!;-,r-11 Amount Paid f% , s Payment Date Payment Type ; ,. Invoice # ChecK if _ Receives y: EHD 48-02-025 SR FORM (Golden Rad) REVISED 1 111 7120 0 3