COMPLIANCE INFO_2005-2012 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN ANTY ENVIRONMENTAL HEALTH ARTMENT SERVICE REQUEST Type of Business gr Property FACILITY ID # SERVICE REQUEST # ACCEPTED BY: EMPLOYEE #:1 S (ZLo J ASSIGNED TO: C O G EMPLOYEE#: 3�7'� 7� .3Ca OWNER / OPERATOR SERVICE CODE: ri n©- 0(tv'C'x Amount Paid ¢dqq 0 CHECK if BILLING ADDRESS FACILITY NAME Payment Type SITE ADDRESS I20 I "��}'yT 336 Street Number Direction Street Name -'Ity 1,21 Code HOME or MAILING ADDRESS (If Different from Site Address) t-� c�_Street Street Number Name CITY (� �k STATE nA ZIP 4� PHONE #1 ExT• (WI ) � 3 �l ��1 APN # N c -240D--Q-:21 LAND USE APPLICATION # PHONE #Z EXT. BOS DISTRICT LOCATIONDE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS _ BUSINESS NAME Q PH ExT. f \/, 177:1 _ _ HOME or MAILING ADDRESS �I f FAX# CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized went 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�3 APPLICANT'S SIGNATURE: D' A�TE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT b 6e-, EprL7 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: ' F- j 'r7 6, -A 'Tl & � '7 1 - I COMMENTS: //4/Q8— J tKSw'z `�wle C iG� Cv �Q1 P� JAN 8 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #:1 DATE: (rr 05 DS ASSIGNED TO: C O G EMPLOYEE#: 3�7'� 7� DATE: �t- Date Service Completed (if already completed): SERVICE CODE: P,E:Ala,7 Fee Amount: 219 * oC, Amount Paid ¢dqq 0 Payment Date // O Payment Type Invoice # Check # Received By: EHD 48-02-025 - - -" 0 go REVISED 11/17/2003 SR FORM (Golden Rod)