COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME f Mo( -C -A ` �E eASTS\oE MOf r -t G VG SERVICE REQUEST # PHONE# Ex* 2-G S'7o —'7725 HOME Or MAILING ADDRESS It \ Q 1 J A ecet o .SEP ' 2 2021 JOAQUIN HEA& M NME 7A# FAX# ( I OWNER/ OPERATOR r' 1 {tNIR OA CHECK if BILLING ADDRESS FACIUTYNAME .CL(AOLC<TC &ASTStDif MA(U�.Ej DATE: SITE ADDRESS '7) 60 C (� [_p p\ A'V E EMPLOYEE #: r7 I l.. p t q 5-21.10 Street Number Direction Street Nam. P / E: it L city Zip Code HOME Or MAILING ADDRESS (If Differing from Site Address) Amount Paid CO V\ C-0-0 St6-eet C-JhCD-iC S -k -6-(2't Street Number 22 2l(/ at Name CmL� C•1 Zip tSATE ct SZ� PHONE APN # LAND USE APPLICATION # [#1�T• PHONE#2 Ems• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR \lt� — A 11V CHECK if BILLING ADDRESS BUSINESS NAME f Mo( -C -A ` �E eASTS\oE MOf r -t G VG !+a -Hal PHONE# Ex* 2-G S'7o —'7725 HOME Or MAILING ADDRESS It \ Q 1 J A ecet o .SEP ' 2 2021 JOAQUIN HEA& M NME 7A# FAX# ( I CITY L STATE C ZIP q S Z 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. APPLICANT'S SIGNATURE: �� DATE: D L 2— PROPERTY / PROPERTY/ BUSINESS OWNER L1 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 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: x I IJik !+a -Hal COMMENTS: Chan Q 1_ W�/�D r I f/ SV1 rk ecet o .SEP ' 2 2021 JOAQUIN HEA& M NME 7A# ACCEPTED B EMPLOYEE #: v DATE: ASSIGNEDTO: AA 0 C✓- EMPLOYEE #: r7 I DATE: Zy Z Date Service Completed (If already completed): SERVICE CODE: P / E: it L Fee Amount: ,U Amount Paid ( Payment Date �/ 22 2l(/ Payment Type h Invoice # I Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 n N 15b, + O ;}