COMPLIANCE INFO_2008-2010 - Laserfiche WebLink

Home Browse Search

NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST • Type of Business or Property AJ 6— A-f� FACILITY ID # BUSINESSM r; e-fY1 � l I �r SERVICE REQUEST # PHON ExT. ( ) (-Lo— HOME or MAILING ADDRESS V r /s7 CITY QJSTATE ©cam;Vy6C OWNER/OPE �OR EMPLOYEE #: �p �� CHECK If BILLING ADDRESS O ' I ( � PIE: I FACILITY NAME CCO I^ I Invoice # SITE ADDRESS 1,-+(09 E` Received By: Street Number Direction Street Name Cit Zip Code HOME or MAILING ADDRESS (If Diffe ent fn Site Address) Street Number Street Name CITY1 1 $TATE ZIP Wn-� 9 PHONE #1 �,V) 47 _ t ExT.•'IJeI/ APN # I CS'e-/s-' V -3t) LAND USE APPLICATION # PHONE#2 ExT• B DISTRICT, LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR cc (� ) AJ 6— A-f� CHECK If BILLING ADDRESS BUSINESSM r; e-fY1 � l I �r PHON ExT. ( ) (-Lo— HOME or MAILING ADDRESS V r FAX # (Z? ) � l c `7 C CITY QJSTATE DATE: ��-ZP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared thi ppll ation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar s, ST E and FEDERAL laws. APPLICANT'S SIGNATURE: DATE.- PROPERTY/ ATE•PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT*Z�pV PICC If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: AJ 6— A-f� COMMENTS: MAS 3 0 2�0$ QUIN COUNTM HATH DEPARIM NS ACCEPTED BY:>L L �% Q ` EMPLOYEE #:�} �e DATE: ASSIGNED TO: 17 GS EMPLOYEE #: �p DATE: Date Service Completed (if already completed): SERVICE CODE: % PIE: Fee Amount:._ �� Amount Paid 0'1Q Q Payment Date 513 a po 0 Payment Type Invoice # Check # b-,�l� l Received By: EHD 48-02-025 SR FORM `( oideri'Ftod) REVISED 11/17/2003