COMPLIANCE INFO_2007-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUWOUNTY ENVIRONMENTAL HEALTIOPARTMENT SERVICE REQUEST Type of Business or Properly CHECK if BILLING ADDRESS Blz&-r FACILITY ID # COMMENTS: RVICEQU ST # HOME or MAILING ADDRESS PU• ACXlG ACCEPTED BY: FA Poo57(7 CITY sit -/C++ -%/t7- C� 2� OWNER / OPERATOR ^ 1 CHECK if BILLING ADDRESS ❑ FACILITY NAME DATE: Date Service Completed (if already completed): SERVICE CODE: et SITE ADDRESS /700 (5yes-ifri,7 f/b�•�. (�%' (G� �c�7iJ j Street Number Direc ion Street Name city Zi Code HOME or MAILING ADDRESS (if Different from Site Address) Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( ') 323-- 7V7 tz, 0-2-190 `L' PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR J REQUESTOR { , vllarK s-4��,eeu /161'Ce'1)9tW-�ete-/ CHECK if BILLING ADDRESS Blz&-r BUSINESS NAME COMMENTS: PH,a�N``E C W. HOME or MAILING ADDRESS PU• ACXlG ACCEPTED BY: FAX # (Z'6`)3G� CITY sit -/C++ -%/t7- j STATE a ZIP gi��S 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, Standards, TE FED L laws. APPLICANT'S SIGNATURE: ` DATE: 3/,t9/e),7 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PAR7Y, 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 availat the same time it is provided to me or my representative. PI M I TYPE OF SERVICE REQUESTED: COMMENTS: U MAR 1 SAN JOAQUIN COUNTY ENSAL H�7H DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: et PIE: D Fee Amount: Amount Paid 315--- E2 0 Payment Date 3 Payment Type invoice # Check # 1 a3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003