COMPLIANCE INFO_1996-1999 - Laserfiche WebLink

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SERVICE REQUEST • Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER OPERATOR Q^ 1 BILUNG PARTY❑ FAcum NAME +Ps SITE ADDRESS ��` _�\� Jy `� h�•,� Street Number Drnxbon �(A X55 s�tP Name y TWO Suite it Mailing Address (if Different from Site Address) CITY S� STATE ZIP C((5 a-O� PHONE#1 E"• APN# LAND USE APPLICATION# PHONE#2 ICT LOCATION 000E; CONTRACTOR I SERVICE REQUESTOR REQUESTOR ^ BILLING PARTYX BUSINESS NAME (.;l E# MAILING ADDRESS FAX# s1 'iKS - CITY ST51 ZIP '-1 �— BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that ad site andfor project specific PUeuc HEALTH SERVICES ENVIRONMENTAL HEALTH OrmioN houtty 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 havcepa this a e wo rrned will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE: OAS= Z� � O PROPERTY I BUSINESS OWN ❑ OPERATOR I MANAGER ❑ OTHER AuniORizED AGENT U�N� \t• �0. trr. It APPwr is not ft SL WG Purry proof of wilmizadon to sign is required Ti ti e AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property bated at the above site address,hereby authortm the release of any and all results,geotechnical data and/or envitonrnentalfsite assessment information to the SAN JOAQUIN COUNTY PuGuC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: I �' FEB 19 1999 r;=NV i i~iti.N IVI Ei\ll TAL H Ee`IJ PERMIT / SERViCE� INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATUR ' APPROVED BY: E9PL,^•Yw 1. DATE: ASSIGNED T0: EMPLOYEE#. DATE: Date Service Completed (if already completed): SERVICECODE: -PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: i