COMPLIANCE INFO_1989-2013 - Laserfiche WebLink

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SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # PHONE # Err. y ��J MAILING ADDRESS FAX# 919 (Ce FZ CrTY STATE OWN RATOR BILLING PARTY MAY o 4 2091 FACILITY $READDRESS FNVIRONMFNTAL HFAITH 010ION `— /V'4 CONTRACTORS SIGNATURE: APPROVED 13Y:. e S *,d Number Wecdon DATE: strut Nana Type Sufis t Mailing Address (If Different from Site Address) Date Service Completed (if already completed): CrTY/—,C STATZIP�� PHONE #1 EXT. APN # Amount Paid a — LAND USE APPLICATION # Payment Type Invoice #' Check 9 5' V —/ O Received By: PHONE #2 UT. BOS:DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR 01 REQUESTOR BILLING PARTY 0 BUSINESS NA}A S / PHONE # Err. y ��J MAILING ADDRESS FAX# 919 (Ce FZ CrTY STATE /4 T ZI/P��c� 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 ENVIRONMWTAL HEAL* DMSi0N 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 FEDERAL laws. APPucANT SIGNA PROPERTY I BUSINESS OWNER 0 to be performed will be done in acoordance with an SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and DATE: '-s' Z /MANAGER 0 OTHER AUTHORIZED AGENT O FAavtcwr is not the Bo Lm Pum proof of authorizadon to sign Is requtrod 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 environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERv10Es EwRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: j T COMMENTS: PAYMENT RECEIVED MAY o 4 2091 SAN JUAUUIN COUNTY PUBLIC HEALTH SERVICES FNVIRONMFNTAL HFAITH 010ION INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: APPROVED 13Y:. e EMPLOYEE (7%S3 DATE: ASSIGNEDTO: EMPLOYEE#: S DATE: D Date Service Completed (if already completed): SERVICECQDE:JqN I.P 1 E: Z�36U Fee Amount: 2 j I Amount Paid a — Payment Date 5`, y —0 Payment Type Invoice #' Check 9 5' V —/ O Received By: