COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN . ,UNTY ENVIRONMENTAL HEALTH L ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # VL FA=-;�y 9 a Ss'c66.7799% OWNIER OPERATOR t , `--21 LIG G7� r-1 JJ`U1 CHECK It BILLING ADDRESS FACILpYNAME�/�.- PHONE# EXT, SITE ADDRESS U (� � L ' ,(�_.1 Y.1ct ICY 1Cl J1lea--moi1Vt DATE: ' �" � Street Number Direction HOME or MAILING ADDRESS tflr Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) CITY L I P / E: ?�Q ^— C -P' Street Number Stre¢t Name CITY STATE Zip PHONE #1 En. APN # Recei LAND USE APPLICATION # l,=" -.�L O PHONE #$ En. 80S DOIS73'C LOCFIN CODE ( ) l�J_ C 1T - CONTRACTOR / SERVICE REQUESTOR REQUESTOR,,— �—L \ �'^-k CHECK If BILLING ADDRESS r w t� 1 �Q LJ i uJv�CL BUSINESSNAME \� ,(� PHONE# EXT, \ ACCEPTED BY: EMPLOYEE #: DATE: ' HOME or MAILING ADDRESS tflr V d Date Service Completed (if a eddy Completed): FAX# (Garp st3- 4CtLA CITY L I P / E: ?�Q ^— C -P' , I -LSI STATE 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, STATE andF AL laws. —7 APPLICANT'S SIGNATURE:j�-0 DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT��[�'(YQf�, l IJAPPLICANT 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: P� COMMENTS:G��-a.0 C� �l�G•�°-- °`. t� �G� i C'� CSC (�S i�(l p CCS �pAIYMC w t� 1 �Q LJ i uJv�CL / �cF/VB ACCEPTED BY: EMPLOYEE #: DATE: ' ^ ASSIGNED TO: 1 J IA 01, EMPLOYEE M DATE:' -7-16-0 Date Service Completed (if a eddy Completed): SERVICE CODE: 15 � P / E: ?�Q Fee Amount:OD Amount Pai 3vc- Cil) Payment Date ] /Q Payment Type Invoice # Check # '73 0 Recei EHD 48-02-025 REVISED 11/17/2003 ved By: j SR FORM (Golden P