COMPLIANCE INFO_2002-2015 - Laserfiche WebLink

Home Browse Search

SAN JOAQUII UNTY ENVIRONMENTAL HEALT�PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # � SERVICE REQUEST # / R5 go t/ ACCEPTED BY: C) OWNER / OPERT, CHECK if BILLING ADDRESS ❑ DATE:&j �p Q CITY STATE zip / FACILITY NAME S • Scch t v, DATE: tom! 0 SITE ADDRESS SERVICE CODE: �Q (G C� 5' P I E: 3 la f- r'+ -Z O G J2i Street Number Direction Street Name Payment Type Ci Code HOME or MAILING ADDRESS (If Different from Site Address) Check # g(-� IReceived By: -ZIL SS Street Number Street Name CITY STATE zip PHONE #1 ExT•APN # LAND USE APPLICATION # ( � ) 9 �- s�� PHONE #2 ExT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTO � •� � � 1 � � � CHECK If BILLING ADDRESS l � BUSINESS NAME PHONE# ExT' R5 go t/ ACCEPTED BY: HOME or MAILING ADDRESS FAX # .0! DATE:&j �p Q CITY 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: � DATE: l'- 30 - d f� PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT14 Sc�dv / QF{c Z l�hhQ/I�GS�� 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:(,LS— tPi IDj r,l � ! , o� — `] 4-8 (l T\AENT COMMENTS: RECEI JUN 3 0 2004 SAN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT ACCEPTED BY: (� j, Lj LG t �O EMPLOYEE #: �l 2 DATE:&j �p Q ASSIGNED TO: 14-A 017 -F— EMPLOYEE #: C/ DATE: tom! 0 Date Service Completed (if already completed): SERVICE CODE: �Q (G P I E: 3 Fee Amount: Z� CI CO Amount Paid -.-2--7'7 Op Payment Date 3b (c) cf. Payment Type L-: - Invoice # Check # g(-� IReceived By: -ZIL EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003