COMPLIANCE INFO_2005-2008 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST 40 Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # 674s s; -�� 0K (,4(t"-3 o s3 OWNER/ OPERATOR ACCEPTED BY: CHECK If BILLING ADDRESS - CITY S''Vcl<--"J STAT ! 4 ZIPgSZ0's EMPLOYEE #: DATE: FACILITY AME co c7 SITE ADDRESS Fee Amount: Amount Paid 9 v C) Payment Date Q / / ,S 3 7 So Street Number Direction (( Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) a)412� n�4 Fi-D�t L T t Street Number Street Name CITY Ao (-t S'o t3 STATE ZIP -% -7 7 67 PHONE #1 EXT• APN # LAND USE APPLICATION # (W ) F3 s -535 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /a�� L� � � CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# CLt7-C 5r-- Co'vi 4Z14C-`1di4 ( EXT. ) Lf(. l - 633 7 HOME or MAILING ADDRESSFAX Q 5 :i � W 1 C c L) 4,— —�l�' i v G ACCEPTED BY: # (Zo ,Y2 - CITY S''Vcl<--"J STAT ! 4 ZIPgSZ0's 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, rE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: �r2 Z /�® PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �C'&o i CL ` 6C)"Eft 6r A- 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:PAYME COMMENTS: DEC 2 7 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: "3t11-, DATE: Z ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: , 47 P I E:. ?J b 21r— Fee Amount: Amount Paid 9 v C) Payment Date Q Payment Type / Invoice # Check # `�✓ / Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)