COMPLIANCE INFO 2009 - 2018 - Laserfiche WebLink

Home Browse Search

----`� i (i S hep 's Civ l GI SAN O JIN COUNTY ENVIRONMENTAL HE "H DEPARTMENT SERVICE REQUEST Type Business o Property V FACILITY 10 # SERVICE REQUEST # PAY M E N T RECEIVED 52ov Co�� ,5 OWNE / OPERATOR CHECK if BILLING ADDRESS , - � ,_ _ ... ENVIRONMENTAL HEALTH DEPARTMENT FACILITY NAME EMPLOYEE#: SITE ADDRESS Vtrx�� r �e street Number Direction StreetJN�am�e City Zip ode HOME Or MAILING ADDRESS (If Different from Site Address) Uj C� ) �7 DATE: 2- iIC I 2— Date Service Completed (if already completed): Date Street Number Sire t Name CITY . /A STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( r 42-1 - -1 Receiv d Byicrj , . PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTORCHECK if BILLING ADDRESS BUSINESS NAME, ��D �y4-,, h 7�, nl n y�, f) )� PHO EXT. HOME Or MAILING ADDRESS � 1 ''%r � FAX #L6L , - I ) -�6/ (p CITY STATE ZIP �jj� � � `� �2a� .._. r .._ BILLING ACKNOWL ,DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii 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 SIGNATUrrR--ttE:)n DATrE::�� � s LS`t ` \� 1`C2UI�FItf1t'i BUSINr!is QWNEIt.Vr -- .C�FER-ATORhA1A.KAJG%- IJaQ _ 0TJFrk.A.UTHOR,I7.ED AGENZ'-l..d 1f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required rwe 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 datatand/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 .. tiMalt to me nr my rrnrecentntive- - - TYPE OF SERVICE REQUESTED: tai S ��7721i/— 7— COMMENTS: COM I ME I NTS: PAY M E N T RECEIVED JAN -A 2012 1 SAN X Aaaw COUNTY _ ... ENVIRONMENTAL HEALTH DEPARTMENT APPROVED BY: �i �. EMPLOYEE#: DATE: ( Z' I2 ASSIGNED TO: o EMPLOYEE #: Uj C� ) �7 DATE: 2- iIC I 2— Date Service Completed (if already completed): Date SERVICE -CODE: I I.PIE: 236 Amount: J - Amount Paid .� Payment Date _ Payment Type - Invoice # Check # . '� Receiv d Byicrj , . EHD 48-01-025^ �r SERVICE REQUEST FORIM ;