COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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SAN JOAQ* COUNTY ENVIRONMENTAL HEA&I DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/ OPERATOR CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS Street Number Direction Street Name -City Zin Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. 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 HEALTIt 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 SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIFR AUTHORIZED AGENT❑ If APPLICANT iS not the&LLING PARTY,proof of authorization to sign is required Title X AUTI-IORI7ATION TO RELEAS,IE► INI+ORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby auth ize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUI OUNTY ENVIRONMENTAL HEALTI-I DEPARTMENT as soon as it is available and at the same time it is provided to me or my represe five. TYPE OF SERVICE REQUESTED: COMMENTS: APPROVED B EMPLOYEE#: DATE: ASSIGNS O: EMPLOYEE#: DATE: Date/rv ice Completed (if already completed): SERVICE CODE: P 1 E: Fee mount: Amount Paid Payment Date P ment Type Invoice# Check# Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02