COMPLIANCE INFO_1985-2005 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN�UNTY ENVIRONMENTAL HEALTF�EPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID ## SERVICE REQUEST # (--�r :LJ i `' �0.327—';&v C" �--' <7�-> ��)V7 � o C�. 1 HpEPARTMENT L1H Ep ACCEPTED BY: OWNER/ OPERATOR CHECK If BILLING ADDRESS EMPLOYEE #: C DATE: FACILITY NAME SERVICE CODE: SITE ADDRESS J Fee Amount: ?��Invoice 1 1 r� re �a� 9` O i(`C" C 19 S 3 7 Street Number Direction Street Name Received By Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT. APN # LAND USE APPLICATION # Oocv � 3S • 4 364 1 PHONE #2 EXT. ( ) BOS DISTRICTLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME NONE # EXT' a o91) y HOME or MAILING ADDRESSter' , \ Q i `' CITY �e i, STATE C" ZIP (I'S2 O ,— 1 HpEPARTMENT L1H Ep 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, Standar , STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT I� If APPLICANT isrl�- 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 me or my representative. • AGNT TYPE OF SERVICE REQUESTED: RECEIVE COMMENTS: COUNTY SAN JOAQUIN HpEPARTMENT L1H Ep ACCEPTED BY: EMPLOYEE #:DATE: ASSIGNED TO: EMPLOYEE #: C DATE: Date Service Completed (if already completed): SERVICE CODE: P! E: 0 Fee Amount: ?��Invoice Paid �a� 9` O Payment Date p PaAmount Payment Type # Check # gS��--. Received By EHD 48-02-025 REVISED 11/17/2003 40 SR FORM (Golden Rod)