COMPLIANCE INFO_2007-2012 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ASERVICE REQUEST G Type of Business or Property FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS 2I2--7 CITY STATE ZIP T C-001�5 9 019 OWNER IOP ATOR A ` I CHECK If BILLING ADDRESS FACILITY NAME�.n DEC 2 1 2009 SITE ADDRESS L-00 R_ tb F�'j L)cv<�, �'TQFJ��G'?Oc�, ° 3 2— 1_4A,7 C 12r-�' ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ©(_ C �- EMPLOYEE #: t/�1 Z Street Number Direction Street Name LU nN Cit Zip Code HOME or I)IIAILING ADDRESS Different from /Site Address) 2 "/T�' C � < L LL C1 DATE: CA -A t— Street Number SERVICE CODE: O& Street Name CITY \ , \t F STATE / n ,t ZIP (,�� 6 PHONE #1 EXT. APN # LAND USE APPLICATION # Payment Type n � Invoice # PHONE #2 EXT. BOS DISTRICT LOCATIOC DE L �J^ FS 61 / 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 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:xc�xw W \ DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICANT 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: CO J P COMMENTS: RECEIVED DEC 2 1 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ©(_ C �- EMPLOYEE #: t/�1 Z DATE: 12— D ASSIGNED TO: LU nN EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: O& PI E: 231)1 Fee Amount: l S Amount Paid Payment Date a Payment Type n � Invoice # Check # Received By: / EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003