COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# /a OoDci5S OWNERIOPERATORf- ,/) 1 ,1A !A 1 //JI E't CHECK If BILLING ADDRESS FACILITY NAME �1 _h 1 1�1I 17-1 -2— Yt IK. q SITE ADDRESS \'�I'l S 1A 1/11 pt1 4 Street Number Direction v`1 f 6 V v Street Name HOME Or MAILING ADDRESS (If Different from Site Address) street Number Slr Name CITY C4V11 \ STATE CA zip 67YO-5 PHONE#t '�T 1(/N(n''1 EXT' APN# LAND USE APPLICATION# 7 (/t/ , PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ,.�•_ y�1 � vvv -il��J11� e(/A CHECK If BILLING ADDRESS BUSINESS NAME ,nom42, P # �( _ ^�Q T HOME or MAILING ADDRESS /2 r ( Y�Urn` 1 J 1 FAX It 7 /a CITY STATE ZIP q57,0 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. 1 APPLICANT'S SIGNATURE: DATE: PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT" t 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 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 i5 available and at the same time It is prOV _Q-me Or my representative. f PAYMENT TYPE OF SERVICE REQUESTED: (NIAVV" RECEIVED COMMENTS: 1 '^S� � APR 11 2019 SAN JOAQUIN COUNTY ENVIRONMENTAL ,*A D.^.^,^^^ HEALTH DEPARTMENT ACCEPTED BY: VYVv •"- =EMPLOYEE#: DATE: A �� VI ASSIGNED TO: L EMPLOYEE#: DATE: 21 j111 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: All I Amount Paid l S2— Payment Date CLO I Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08