COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #IKX0011:w�?Z- fps �O�Zy 3C5 VICE REQ EST # OWNER OPERATOR S7 IJi^ 7 / , �/T .1 v` CHECK if BILLING ADDRESS FACILITY NAME �O (;Y -A,1'0! t `J ,n i�.,^v `-73155 CIN SITE ADDRESS Street Number S Direction 1A I/1161.i- SF Street Name S Cil ZI Code HOME or MAILING ADDRESS (If Different from Site Address) 2� 3 Street Number t� 1/1 eU --y-t-• C+ f -t �✓ t� i Street Name CITY S��y 1/'-� ^ LA•YQ/JgU/"�i STATE /1A. ZIP "I ExT• PHONE #1 /�j,{ X71 W4) "lI -- jell APN# EMPLOYEE #: LAND USIE/AP�PLICATION# PHONE#2 T• ( ) SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �^ ' CHECK If BILLING ADDRESS BUSINESS NAME -t o I/�,,/t � /'tel PH;t!N� q I n S HOME Or MAILING ADDRESS � i V 3 S A � VI �� `AX%l#/-I)L CIN STATE OA ZIP 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 TATE pnd FEDE aws. APPLICANT'S SIGNATURE: � �- DATE: I PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 I'APPLxANT 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 environnlentallsite 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:�Ej y PA COMMENTS: APR 0 7 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: L-1 ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: tui, Fee Amount: A 1 Amount Paid C S Z — I Payment Date / Payment Type Invoice # # 12 C) Z 7 � Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003