COMPLIANCE INFO_1998-2003 - Laserfiche WebLink

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r Type of Business or Property SERVICE REQUEST FACILITY ID # M- EHOO61SR revised 09/04/98 SERVICE REQUEST # 0 t 13V 9 r OWNER I OPERATOR n � . �., .z I� a..v�i' � a S i"tc w t r+-►� ar, BILLING PARTY ❑ FACILITY NAME SITEADDRESS BILLING PARTY El BUSINESS NAME -� � `j � � N. i MLiG �L i 1 ✓� '' OTHER PHONE # ��' . y EXT. c'% 2- Z'' � I1' 4-� Direction Sbvet Name Type Suite# Mailing Address (If Different from Site Address) G c v i 2-i�— CITY i � S06- zIP� PHOE #1 EXT. APN # LAND USE APPLICATION # AP,,', �E 42 EXT. BOS DISTRICT LOCATION CODE i CONTRACTOR / SERVICE REQUIESTOR REQUESTOR, e-r`6 BILLING PARTY El BUSINESS NAME -� � `j � � N. i MLiG �L i 1 ✓� '' OTHER PHONE # ��' . y EXT. c'% 2- Z'' � I1' 4-� MAILING ADDRESS PO FAX # (1!44 31s111 -7;�=�"� CITY -P lc.� ► t C�+�{�% STATE 64-- zip [7s &7 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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, S ao'Vs. APPLICANT SIGNATURE: 4�,,tf DATE: PROPERTY I BUSINESS OWNER OPERATOR I 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 PUBLic HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided t0 me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER _ OCT 2 2 1998 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES --- _._._._.....------....... -- ..._ _..------........._..--- -- --- ------ ----.. INSPECTOR'S SIGNATUREDTv\: ^ CONTRACTOR'S SIGNATURE: ENVIRONMENTAL HEALTH I ION -- - _..._.._..... _..._...... -- --_ _ - DATE' ^zL� APPROVED BY: Z ai ASSIGNED TO:� JL EMPLOYEE #: EMPLOYEE C) eDATE: DATE: �� .- ZZ- Date Service Complete (if already completed): SERVICE CODE: ®3 PIE: p Fee Amount: ' Zp-2- Amount Paid-7pZ _ Payment Date Payment Type invoice # Check eived By: