COMPLIANCE INFO 2013-2015 - Laserfiche WebLink

Home Browse Search

SAN JOAOPCOUNTY ENVIRONMENTAL HEALTH91PARTMENT SERVICE REQUEST Type of Business or Property l RFCF A r FACILITY ID # CRECKif BILLING ADDRESS SERVICE REQUEST # Gas Station PHONE # Ex . - 010 S`1 R om 3 OWNER / OPERATOR HOME or MAILING ADDRESS CHECK If BILLING ADDRESS Tower Energy Group #: FACILITY NAME CITY West Sacramento STATE CA ZIP 95620 Tower Mart #104 DATE: Date Service Completed (if already c pleted): SITE ADDRESS 192 SERVICE CODE: 1,1 Lathrop Road Fee Amount: 7t) v — Lathrop 95330 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1983 West 190th Street Street Number Street Name CITY Torrance STATE CA ZIP 90504 PHONE #1 En. APN # LAND USE APPLICATION It ( > l�b-130 -0 4PHONE #2 EXr. BOS DISTRICT LOCATION CODE ( > ID CONTRACTOR / SERVICE REQUESTOR REOUESTOR l RFCF A r Veronica Freitas CRECKif BILLING ADDRESS BUSINESS NAME 4%4?S?014 PHONE # Ex . Walton Engineering, Inc. (916)373-1167 HOME or MAILING ADDRESS E11 FAx # P.O. Box 1025 #: (916)373-1173 CITY West Sacramento STATE CA ZIP 95620 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. 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: 08-25-14 PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Contractor If APPLICANT is not the BILLING PARTY, Proof of authorization t0 sign t5 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 t0 me Or my representative. PA%,.- TYPE OF SERVICE REQUESTED: l RFCF A r COMMENTS: 19 6 4%4?S?014 MEkN%gOA' 'hY 'tL E11 ACCEPTED BY: rn, A =EMPLOYEE #: DATE:-, /v0 ILL VASSIGNED TO: (J ei'l EMPLOYEE#: DATE: Date Service Completed (if already c pleted): SERVICE CODE: 1,1 PIE: Z�Cig Fee Amount: 7t) v — I Amount Pai 390.0a 1 Payment Date Payment Type Invoice # Check # 48' `-j( Received By. EHD 48-02-025 SR FORM (Golden Rod) 07/17/08