COMPLIANCE INFO_2008-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # PHONE# ExT• (-'-A C790 6f`ES 5CC0051o1b OWNER/ O^!R".TOR/� D 61 P (AD 1O i/`_S / Z' Y CHECK If BILLING ADDRESSO / o FACILITY NAME FL- MUT SITE ADDRESS EMPLOYEE M 0 Date Date Service Completed (if already completed): SERVICE CODE: d J Im Number rection Amount Paid ) 3 Payment Date a S III j Payment Type CotS� F. ME or Mf :i.ING ADDRESS (If Different from Site Address) �<_ A) T r- c57A- STAF_ F r_. Received By:? Street Number Street Name CITYA/� � C Y 7 A5 STATE ZIP -:--7 PHO E #1 Exr. 0) APN # LAND USE APPLICATION # P 0 #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE# ExT• HOME or MAILING ADDRESS FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, 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 ccordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. - / /� r�[^/1 � � ��DJ>y APPLICANT'S SIGNATURE: AL] �/ /I J!r I `DATE: 6 PROPERTY / BUSINESS OWNER OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT, 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 t0 me Or my representative. TYPE OF SERVICE REQUESTED: IA -9 F PAYMMI COMMENTS: RECEIVED AUG -2 5 2016 SAN JOAQUIN COUNTY ENVIROMENTAL M ACCEPTED BY: EMPLOYEE M DATE: ZS / b ASSIGNED TO: S— EMPLOYEE M DATE: 2 - Date Date Service Completed (if already completed): SERVICE CODE: d J P /E:_2 -J3 I Fee Amount: Amount Paid ) 3 Payment Date a S III j Payment Type CotS� Invoice # Y Check # Received By:? EHD 48-02-025 07/17/08 L�_, SR FORM (Golden Rod)