COMPLIANCE INFO 1999-2006 - Laserfiche WebLink

Home Browse Search

SAN JOAQUINr- OUNTY ENVIRONMENTAL HEALT DEPARTMENT • SERVICE REQUEST Type of Business or Property 2AD FACILITY ID # SERVICE REQUEST # Gc.�:' �` ; PHONE# aci EXT' 461 6 3 c Saoc/11ds _ ) `161 -63y CITY`-9�C\ STATE 0 GI ZIP 01-5-10,5— OWNER/ OPERATOR ASSIGNED TO: I EMPLOYEE#: 0-75 5� Date Service Completed (if already c pleted): CHECK If BILLING ADDRESS FACILITY NAME 1 P I E: 1:3-36700, Fee Amount: a a �Q Amount Paid Payment Date ?/X OS Payment Type ✓ SITE ADDRESS Check # 4�, 1 Street Number Direction Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Str¢et Name CITY STATE ZIP PHONE #1 EXT' APN # LAND USE APPLICATION # (2v9) 11�s-3ti`I(3 PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR W [� 2AD �J� CHECK if BILLING ADDRESS Lr1J BUSINESS NAME t t © rC,C- PHONE# aci EXT' 461 6 3 HOME or MAILING ADORES 1�s3 u', FAX# av5 ) `161 -63y CITY`-9�C\ STATE 0 GI ZIP 01-5-10,5— 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. L_ APPLICANT'S SIGNATURE: DATppE:I � - .26 - O� PROPERTYIBUSINESs OWNER❑ OPERATOR(MANAGER❑ OTHER AUTHORIZED AGENTrw �Ll �� If APPLICANT is the BILLING PARTY Proof ofauthoriZation 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. rn 1T TYPE OF SERVICE REQUESTED: /CEIVE � 2AD COMMENTS: 6 2005 �p 2 COUNTY SAN JOAOUIN ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: YEE M 76yq DATE: _ ASSIGNED TO: I EMPLOYEE#: 0-75 DATE: Date Service Completed (if already c pleted): SERVICE CODE: I 9 6, 1 P I E: 1:3-36700, Fee Amount: a a �Q Amount Paid Payment Date ?/X OS Payment Type ✓ Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)