COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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REQUESTOR BILLING PARTY ❑ BUSINESS NAME PHON # - P�� MAILING ADDRESS *1/ ynCITY STATEL� ZI 4"—;,-14 —t ^f emmsx nrlrnnwledae that all site BILLING ACKNOWLEDGEMENT: I, the unaerslgnea prupeny Ut uuaurc.a .,-�•-•-• -• --- - --- and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL_ HEALTH DIVISION 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 preps m this application and that the work to be performed will be done in accordance with II SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST a EDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑ TOR/MANAGER ❑ OTHERAUTHORREDAGENT If APPUCJINT is not the BWNG 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 +.. Orr- —11 C --^o wrKMAJ NGo, TM rnvlsinN as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: N SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER Cl SEfZVICE REQUEST EH0061SR revised 09/04/98 Type of Business or Property FACILITY ID # SERVICE REQUEST # SEP BILLING PARTY ❑ OWNER I OPERATOR ENVIF',C^JTv1ENTAL H - RVIVI SALT HDIVISIGI, FACILITY NAME CONTRACTOR'S SIGNATURIZ: DATE: SITE ADDRESS �d EMPLOYEE #: ®d ® Type Suite 3 DATE: 'iL Street Number Direction Street Noma I Mailing Address (if Differ t from Si Address) DATE: I A$SiGNED T0: I Date Service Completed (if already completed): $ERVIC'c CODE: STATE ZIP �- Fee Amount: CITY Amount Paid (o y Payment Date �f PHONE #1 EXT. APN # LAND USE APPLICATION # Invoice # 33 i Check # Received By:' PHONE #2 aT• BOS DISTRICT LOCATION CODE cnNTRACTOR 1 SERVICE REQUESTOR REQUESTOR BILLING PARTY ❑ BUSINESS NAME PHON # - P�� MAILING ADDRESS *1/ ynCITY STATEL� ZI 4"—;,-14 —t ^f emmsx nrlrnnwledae that all site BILLING ACKNOWLEDGEMENT: I, the unaerslgnea prupeny Ut uuaurc.a .,-�•-•-• -• --- - --- and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL_ HEALTH DIVISION 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 preps m this application and that the work to be performed will be done in accordance with II SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST a EDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑ TOR/MANAGER ❑ OTHERAUTHORREDAGENT If APPUCJINT is not the BWNG 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 +.. Orr- —11 C --^o wrKMAJ NGo, TM rnvlsinN as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER Cl PAYM E NI ItsFQ,tr-n apvm� SEP SAiV JOAWUlN C: