COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# FAO®D 1Z9 ` �3 3 OWNER/OPERATOR �-� CHECK If BILLING ADDRESS❑�� ► <� C�sty l I C)FACILITY NAME SITE ADDRESS 2 s3 � �� , � G15ZC Street Number Direction Street Name ci Zi Code HOME Or MAILING ADDRESS (ifDifferentfromt Site Address) v 1 Street Number Street Name CITY Z �^ ,�.-4-j STATE O/^} ZIP PHONE#1 EXT. APN# LAND USEAPPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR p �`^ CHECK if BILLING ADDRES C_ BUSINESS NAME (r Y , Vv t 1 t ` ` PHO �EX�. HOME Or MAILING ADDRESS ?b?b 1Z �l FAX# CITY C`/ STATE CA- 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 thi fo ' rm. I also certify that I have prepared this applica n and tha he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d FEDE laws. APPLICANT'S SIGNATURE: ,tel^ ) DATE: PROPERTY/BUSINESS OWNER RATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT Is t the B LI G PA TY,proof of uthorization to sign is required Title AUTHORIZATION TO RELEA E IN RMATI N: When plicable, I, the owner or operator of the property located at the above site address, hereby authorizo the elease of ny and al esults, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY E NMENTAL HE LTH D RTMENT as soon as It Is available and at the same time It Is provided to me or my representative. �I TYPE OF SERVICE REQUESTED: % •M COMMENTS: �\_G�Y1G�Q orf r/� r :'%*O MAr �o ,dIeNvl o ?41, yA QU/N 1-�46 N FP F,Colj ACCEPTED BY: n ,t/I EMPLOYEE#: DATE: . ASSIGNED TO: v 'N Q /�rJ r�� EMPLOYEE#: DATE: _kr) <^ Date Service Completed (if already completed): SERVICE CODE: PIE: O Fee Amount: Amount Paid l s� Payment Date 5 Payment Type �( Invoice# Check# Received By- EHD 48-02-025 SR FORM(Golden Rod) 07/17/08