COMPLIANCE INFO_2007-2012 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST dh Type of Business or Property FACILITY ID # �, SERVICE REQUEST # HOME or MAILING ADDRESS "S, -7 CITY (/Z r h STATE ZIP l7 1 VE, SAN JOAQUIN COUNTY OWNER/ OPERATOR CHECK If BILLING ADDRESS FACILITY NAME ACCEPTED BY: SITE ADDRESS ?� ?�- W�.lJi7 fZ( �� C iF Ln Gtr Y17J Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) C% - L` 10 G ��' i w "--I Street Number DATE: Street Name CITY _1 . STATE ZlP Sid .3 PHONE#t EXT. ApN#� LAND USE APPLICATION# (14q ) kli G - S� I fo � �/ / O�"' Payment Date 4111 1 D PHONE #2 EXT. (tea) �-is�3 - S'�i i� BOS DISTRICTLOCATION CODE 77 CONTRACTOR / SERVICE REQUESTOR REQUESTOR ," �� I i M (� CHECK If BILLING ADDRESS BUSINESS NAME C1 ct,V �, PHONE HONE# EXT. ( �cIsI� HOME or MAILING ADDRESS FAX # CITY (/Z r h 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: <2)a,Q S) A" DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required H - -s- , D 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: �s�RECEIVED COMMENTS: I ea1L t7i.e'� e� Fpl's �` �oG f47 4 APR 11 2007 D�iSei l7 1 VE, SAN JOAQUIN COUNTY V ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: fi Y DATE: ! Q 6 ASSIGNED TO: C% - EMPLOYEE #: / J DATE: Date Service Completed (if alrea4 complete SERVICE CODE: PIE: Fee Amount: 27-- Amount Paid 9 --- Payment Date 4111 1 D Payment Type Invoice # Check # Received By: EHD 48-02-025 tS'R FORM (Golden Rod) REVISED 11/17/2003 __-