COMPLIANCE INFO_2023 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK ItBILLING ADDRESS SERVICE REQUEST # tA� M„ #. srtoFtO093 OWNER / OPERATOR CHECK If BILLING ADDRESS I- HOME Or MAILING ADDRESS FACILITY NAME FAX`r#'YI 14 1 / Li C ( 1 SITE ADDRESS J/ lu I CITY t—,r C) {— 1 ` G Y'\ ZIP Z 5 q p,d�7l./tYl O/"J j yl h�,..�s 1 �tt ? Gi�3 Street Number Direction SERVICE CODE: Slrle�t Nama Fee Amount: Zip Code HOME or MAILING ADDRESS (If Different from Site Address)ZZ Payment Date 3 / Payment Type I 1 Y)1-- -Dy , 2 z str�umber Received By: (` Street Name CITY1DAeSi CA- ZIP b� PHONE#t Err. APN # LAND USE APPLICATION # PHONE #2 Err. ( 1 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 0rf71IY7G T dL� CHECK ItBILLING ADDRESS BU,SINESSLTVPiO tA� M„ #. �� nrnE>7' VO c�[J dO 014MENT HOME Or MAILING ADDRESS FAX`r#'YI 14 232IFSY311 / Li C ( 1 EMPLOYEE I� CITY t—,r C) {— STATE ZIP Z 5 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. 2 APPLICANT'S SIGNATURE: fEL DATE: 1 ILA �20Z3 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I,fAPPLICANT 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 avail,�ileaft 0"Vame time it Is provided to me or my representative. �r+AA�7 ��`�'' TYPE OF SERVICE REQUESTED: SUI a yl COMMENTS: tA� M„ COUNV c�[J dO 014MENT ii DEPARTMENT 14 ACCEPTED BY'/It{� / Li C EMPLOYEE I� DATE: 3 1 Z3 ASSIGNEDTO: q p,d�7l./tYl O/"J j yl h�,..�s EMPLOYEE#: DATE: 3 , q 73 /j Date Service Completed (if already completed): SERVICE CODE: P / E: 1_ , b-3 i v� Fee Amount: Amount Paid �S Payment Date 3 / Payment Type Invoice # Check # Received By: EHD 4M2-025 REVISED 11/17/2003 SR FORM (Golden Rod)