COMPLIANCE INFO_2014-2017 - Laserfiche WebLink

Home Browse Search

r R SAN JOAQAOUNTY ENVIRONMENTAL HEALTH EMZTMENT SERVICE REQUEST Type of Business or Property �� ^^FACILITY ID # / �SEQRVIICEE RRE UES �� ll0� A 000 Oh-""��J YO-WINER/ OPERATOR � - n CHECK If BILLING ADDRESS FACILITY NAME nn lan SITE ADDRESS P" U 1 % c ux f— lr�C...l\ C.JJ / Street Number Direction EMPLOYEE #: Street Nzme City Zi o�CSode H E Or AILING ADDRESS (If Different from Site Address) Date Service Completed (if�alreUady completed): SERVICE CODE: / l Street Number Street Name CITY STATE ZIP PHONE #1 EXT. (9-09),In-5-lip APN # LAND USE APPLICATION # 1 5 32-900? Payment Type ? ` Invoice # ill # [(,)()57 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) 0 j t", - CONTRACTOR / SERVICE REQUESTOR REQUESTOR � / _ f � � LJj� l.l� CHECK If BILLING ADDRESS ED BUSINESS NAME COMMENTS: PH�oaNE# EXT. J FEB 13 2015 J HOME or MAILING ADDRESS 0)- SAN JOAQUIN COU FAX # P" U 1 % c ux ENVIROMENTAL c ) CITY J Abc- STATE ZIP A D 1\ EMPLOYEE #: 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. also certify that I have prepared this appl' on and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE ) Z)D /f PROPERTY/ BUSINESS OWNERt,� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I/ ; (9 Lmi xz-1-6 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 t0 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: (It 5 tr �� j kj PAYMENT COMMENTS: RECEIVED - FEB 13 2015 SAN JOAQUIN COU ENVIROMENTAL HEALTH ACCEPTED BY: l EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if�alreUady completed): SERVICE CODE: / l P/E: Z3 Fee Amount: L 3 p Amount Paid — Payment Date -2— j3 15r Payment Type ? ` Invoice # ill # [(,)()57 Recei ed By: EHD 48-02-025 SR FORA/I (Golden Rod) 07/17/08