COMPLIANCE INFO_2018-2018 - Laserfiche WebLink

Home Browse Search

Type of or SAN JOAQUIN',...JUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Owl,' ^/ OPERATOR FACILITY NAME _ n i� /% /J SITEADDRESS HON, Or'IAIL,_-',00RESS �L"�) CITY , PI ZONE #1 PI,ONE#Z FACILITY ID # rp as )-:� qc�)e 11"mole- a//9y/ _ street Nzin: _ I ., ent from Site SERVICE REQUEST # -- =h -CN h BILLING ADORE-_:.�( s%OC/�i�Q�/11S�7G6 STATEex EXT' APN# i f--TLAND USE APPLICATION.# y! EK' BO: CISTRICT LOCATIC 4 Co,,5 CONTRACTOR / SERVIC E REQUEST01; REOUESTOR -l"1-,J ` ( JR CHECK If 1311-1-1'+G ADDRESS BUSINESS NAME o/f G/r y/'o Silow i7E PHONE # EXT. 9 6 _- S-dSf/ HOME or NiAILINGADDRESf 1-12 p /4 /�%/ FAX# ( ) CIN !'% C./L STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or author'zed agent of same, acknowledge that all site ind/or preiert POeclfic ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associat-i with 'his project ^r acEvlty will be billed to me --T my business as Identified on this form. I also certify that I nave prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN CoLrY Ordinance Codes, Standards, STATE and FEDERAL laws. Ar PLICANT'S SIGNATURE: _I461 lgitt �7 - DATE: �1Z0 PROPERTY / BUSINESS OWNr I' OPERATCR / MANAGER❑ OTHER AUTHORIZED AGENT 1:1/ _ li APPLICAA r s not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property : )cateo at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite as.essment i.ifr rmation t0 the SAN JOAQUIN COUNT', ENVIeONMENTAL HEALTH DEPARTMENT IS. Soon as it is available and at the same time it is provided to me. or my representative. oA TYPE OF SERVICE REQUESTED: _ �✓151D�C�lO YI RECEIVED COMMENTS: AUG 1 0 2016 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: t ?i 1 V� EMPLO?EE #: DATE: ASSIGNEr TO: E:MPLOVEE #: D4TI,: <2 3ie Service Completed (if already completed): SERNCE CODE: — Pi E: Fee Amutmt: Amount Paid 3 Payment Date _ Payment Type if Invoice Check # j Received By: EHD 48-02-025 ✓ (• O 07/17/08 J SR FORM (Golden Rod)