COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # COMMENTS: ^l� ID l 2 � 52Oo "7G0.2-1 ,OWNER /OPERATOR�� ' A r �� r jO�r C � (st l/ CHECK If BILLING ADD RESS❑ ,/V Q FACILITY NAME SAN oil AQU/N C tiE ,SiiE ADDRESS/� LJ�1 I ld" DOE AR A ACCEPTED BY: ('t' \ EMPLOYEE #: lreet Number Direction �J Straet Name EMPLOYEE M C'ri 21 Cotle HOME Or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: y „), PIE: j (oD� Street Number �p (J Street Name CITY STATE zip PHONE#1 Enr' APN # Check # -7 S 7 3 LAND USE APPLICATION # ( ) 2 tzD5 Ob HONE#2 Ext BOS DISTRICT LOCATION CODE t 1 05 1v CONTRACTOR / SERVICE REQUESTOR REQUESTOR CT Pl (Q/) ,/V l(ZSC7 Kyle M&PI nfi2 NECK If BILLING ADDRESS -BUSINESS NAME Qtr.r Pod keS ' Pt- ^h L3 41 IC( COMMENTS: PHONE# EXT. 2 C52- �lb'y3 HOME Or MAILING ADDRESS,,/,,n /Ir rrU,)� e (, I�(�j �V C (� �cilY�� s �►� (AX# ) CITY rrnvn STATE CA 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, St dards, SIATE and FEDERAL laws. APPLICANT'S SIGNATURE: ��—DATE: 7 dG /l PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IfAPPLIC4,VT is not the BiLLiNGPAR 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 HEAL!m DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: J[) A t"j 4 j- yvUbu Pqy COMMENTS: I , �Fie�L-S T,II-`� :- I t,L 5 �ui't �� H �> YGUi k �cilY�� s �►� 8 ?0 SAN oil AQU/N C tiE ld" DOE AR A ACCEPTED BY: ('t' \ EMPLOYEE #: DATE: ASSIGNED TO: 0') t S'5 . VI -k EMPLOYEE M DATE: Date Service Completed (if already mpleted): SERVICE CODE: y „), PIE: j (oD� Fee Amount: �p (J Amount Paid C d. v� Payment Date 7/Vi, Payment Type Invoice # Check # -7 S 7 3 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) Nry Nr