COMPLIANCE INFO_2007-2018 - Laserfiche WebLink

Home Browse Search

v.aa. v vaa�vaa 1 vV V11 a 1 Ll \ 111�Va 11r11:a1\ lAL lllJAL111 L1L1 Al�larll�•\ 1 , SERVICE REQUEST Type of Business or Property BUSINESS NAMEPHONE# Exr' FACILITY ID # Q u 9 W23-747-4 SERVICE REQUEST # FAX # ENVIRONMENTAL CITY STATE ZIP ACCEPTED BY: EMPLOYEE M (, / I DATE: ASSIGNED TO: EMPLOYEE M � � DATE: —r/- vvvttt 7erqs Fee Amount: Amount Paid ci SY Payment Date -7 Payment Type �; Invoice # OWNER/ OPERATOR Received By: ❑ CHECK If BILLING ADDRESS ACJ FACILITY NAME a �� / J�1` 6, SITE ADDRESS 0-0 es,M oor e -"J` 1 33 6 Street Number Direction Street Name city Zip 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 #T ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR y CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# Exr' w tr dl e pe+va )-,P ► W -r -t -t Q u 9 W23-747-4 HOME or MAILING ADDRESS FAX # ENVIRONMENTAL 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 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 7' 1/' 57 PROPERTY/ BUSINESS OWNER CJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the 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. TYPE OF SERVICE REQUESTED: �5 RECEivFn COMMENTS: !/ /�L , n„ A /- �� JUL 1 1 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE M (, / I DATE: ASSIGNED TO: EMPLOYEE M � � DATE: —r/- vvvttt -- Date Service Completed (if already completed): SERVICE CODE: P& P I E: Fee Amount: Amount Paid ci SY Payment Date -7 Payment Type �; Invoice # Check # ! c'73 Received By: EHD 48-02-025 7/-2-410-7 C,,LU d rREVISED 11/17!2003 e--'d� �v�( {g�Gt-� G✓� Fc�t,J'Gzi/� 6t,a# q2s 3S3 e0S3 (Ta✓"i --