COMPLIANCE INFO_1999-2011 - Laserfiche WebLink

Home Browse Search

SAN JOAQUWOUNTY ENVIRONMENTAL HEAL*EPARTMENT SERVICE REQUEST Type of Business or Property ❑ FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # Communications PH E# EXT. 3 ?3 o C- I U£ I - -SV o o (p // (, 2- OWNER/ OPERATOR OWNER/ I0 --2 FAX# 2766 Pomona Blvd CHECK If BILLING ADDRESS ❑ FACILITY NAME Verizon Manteca CO STATE CA ZIP 91768 DATE: / D SITE ADDRESS 430 I West Center Street I P I E: wog Manteca 3 & F95336 Street Number Direction Street Name Payment Type city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # ` Hampshire Street 1 Received By: Street Number Street Name CITY STATE ZIP Lawrence MA 01840 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 978 ) 837-3604 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ❑ PAYMENT CHECK If BILLING ADDRESS BUSINESS NAME PH E# EXT. SunWest Enginering Constructors, Inc. o C- I U£ I g�9 594-9850 HOME or MAILING ADDRESS I0 --2 FAX# 2766 Pomona Blvd ( 909 ) 594-6169 CITY Pomona STATE CA ZIP 91768 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: PROPERTY /BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (//✓�i�.lT_.r�! 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: ((S% Zed F i T PAYMENT COMMENTS: OCT m t 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: o C- I U£ I EMPLOYEE M I0 --2 DATE: 6 �� ASSIGNED TO: EMPLOYEE M 2 & DATE: / D Date Service Completed (if already completed): SERVICE CODE: (!r` (T P I E: wog Fee Amount: 3 & Amount Paid `3 lo L— Payment Date , p O Payment Type Invoice # Check # ` 2_ -L 2 5 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003