COMPLIANCE INFO_2010-2015 - Laserfiche WebLink

Home Browse Search

SAN JOAQLU COUNTY ENVIRONMENTAL HEALTVDEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # ZOWNEmopZ(2- HOME Or MAILING ADDRESS62-99 � & P TY " � \ ,� M TI A M m b (, S„T & � � SERVICE REQUEST # R/ OPERATOR OWNER/ /� A •-{` , 0 1 r, I � A 1' r �� ^rAn ^ �� l.1 ( nll CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESSt, St_rleet Number I Direction * A S b f� LC 'P,� Street Name Ft, A-'0 h D Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number MEN. Street Name CITY STATE ZIP PHONE #1 EXT• ( ) APN # LAND USE APPLICATION # PHONE#2 EXT. ( ) DATE: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 1C V 6- Lo{ (.ii� -7 IN C- CHECK If BILLING ADDRESS BUSINESS NAME PHONE#EXT' 7 3 s' 1 I HOME Or MAILING ADDRESS62-99 � & P TY " � \ ,� M TI A M m b (, S„T & � � FAX # ( ) CITY /� v I^ S STATE Q-A ZIP /� �1 1 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 ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S TE and E laws. Q APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER T OTHER AUTHORIZED AGENT ❑ T77 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 same time it is provided to me or my representative. IbA MENT TYPE OF SERVICE REQUESTED: D COMMENTS: SEP 0 9 2014 BA ENVARO oN COtINTy HEALTH DE ARTAL MEN. ACCEPTED BY: NI��(�- EMPLOYEE#: DATE: 7 ASSIGNED TO: �% ��N EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Z30 0 Fee Amount: 3 ._ --� Amount Pai 3C j� �� Payment Date �i c, % L4 Payment Type Invoice # Check #l I Received By: / 4- -- EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003