COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

KkTtwlG11 • DEC 12 2016 Ali HI OAQUIN COUNTY SAN JOAQUecOUNTY ENVIRONMENTAL HEALTIOEPARTMENT SERVICE REQUEST FACILITY # SERVICE REQUEST # A� � j��J►p�roperty �I�D/� /(W F OWNER / OPERATOR CHECK if BILLING ADDRESS - A/1 v r �� 1 ,� S1 YJQ � FAX# ( 209 ) 465-4988 FACiLIIY NAME it STATE CA ZIP 95213 q rC"? Ccs Ja ) k? DATE: O t� SITE ADDRESS , � C iL PIE: 23 08 Fee Amount:1 `� .t- a O g• S 5-J(' JqDI Street Number r i n a /:z S Payment Type Cc S e, Cit C HOME or MAILING ADDRESS (H Different from Site Address) =Strt Street Nam CITY STATE Zip PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT LOCATION CODE (510 ) 557- L15'0 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS® BUSINESS NAME Service Station Testing - SST INC / CSLB 962520 COMMENTS: �i�t i✓t�J' F_X t 5ff rI � (�SS�Ir (u.''x i,% �'iC'' �(ic�EtlC[YlJ E]ci5ft�l 1�t2'SS('r^ `JG yY1e'. �Avv F�lfx�f�5. PHONE# EXT. 209 465-5577 HOME or MAILING ADDRESS PO Box 31465 41h FAX# ( 209 ) 465-4988 CITY Stockton STATE CA ZIP 95213 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: I Z -(2 -41 PROPERTY/BUSINESS OWNERL"J OPERATOR/ Na R ❑ OTHER AUTHORIZED AGENT ® President If APPLICANT is not the BILLINGPARTY 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: COMMENTS: �i�t i✓t�J' F_X t 5ff rI � (�SS�Ir (u.''x i,% �'iC'' �(ic�EtlC[YlJ E]ci5ft�l 1�t2'SS('r^ `JG yY1e'. �Avv F�lfx�f�5. .1/�j�1t Rf,:: /�Lf. eS Cif f1 Cit/�:rtv ACCEPTED BY: & Ich6 41h EMPLOYEE #: I DATE: ASUGNED TO: UI F ILAi EMPLOYEE #: DATE: O t� Date Service Completed (it already completed): ��Iti SERVICE CODE: PIE: 23 08 Fee Amount:1 `� .t- a O g• S Amount Paid C 1 7 c d 0a $ S Payment Date a /:z S Payment Type Cc S e, Invoice # PAYME heck # ----- -- Received By.,25:,- 48-02-025 REVISED 11/17/2003 DEC 19 2016 — 7 SAN JOAQUIN COUNTY ENVIROMENTAL L_ J SR FORM (Golden Rod)