COMPLIANCE INFO_2013-2014 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY I�D�l REQUEST # GDF �c L) 6 TT 3 C71� lJ# �rySE�RVICE � 6 OWNER I OPERATOR_ /� A �M M !SS o � A � e- P � � � oL�t,�r� f � C' . CHECK if BILLING ADDRESS FACILITY NAME Tracy Valero F # ^ e� CITY vtqnfa-f) f, SITEADDRESS 2375 N I Tracy Blvd I ACCEPTED BY: fi-EMPLOYEE Tracy 95376 Street Number Direction EMPLOYEE #: Street Name Date Service Completed (if already comp d): city Zip Code OME Or MAILINGADDRESS (ifDifferent from Site Address) Fee Amount:p �— Amount Paid Payment Date 0 Payment Type Invoice # /�I eOT ' Street Number Street Name CITY t �Ve� _tAM-- Y L u f ` STATE CA ��1 P NE #11 EXT APN # LAND USE APPLICATION # cti5) �}r�(�- 5�b� (13L— d� C _0 PHONE #1 EXT. c 025) IQ� " 5 6D BOS DISTRICT T LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR AA t �/� } I -W I� 1 M CHECK If BILLING ADDRESS BUSINESS NAME I n PHQN2 # 4,56 _ J Exr. HOME or MAILING ADDRESS Q OCT � JOAQUIN COUNr F # ^ e� CITY vtqnfa-f) f, STATE /1 p ZIP Lt�r 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: U,1 �'� / '�--+� DATE• f I L1 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: MF lVED COMMENTS: LATE PERMIT APPLICATION: 2014 T� ATG Coldstart performed 10-29-2013 OCT � JOAQUIN COUNr U 87 MLLD replaced 12-06-2013 MEALMTH DEPARTVIROMUNTN ACCEPTED BY: fi-EMPLOYEE #: DATE: / ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already comp d): SERVICE CODE: l PIE: U u Fee Amount:p �— Amount Paid Payment Date Payment Type Invoice # Check # Re eivediy:ET EHD 48-02-025D� 1 SR FORM (Golden Rod) REVISED 11117/2003 "'"'"7777 �ttl (-