COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# AQC)032_3e'1 Sc' Qb-1 avL{ OWNER/OPERATOR ' CHECK If BILLING ADDRESS FACILITY NAME A0 to n V�74 1 ,oi I V Vt `` n A-(Y—P-4— SITE ADDRESS O�ZS C e V 1+y-9 00 /`� -TV-C4� 0) s-;5-7(,Street Number Direction Street Name Ci Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY ��V ` STATE ZIP q1 21 PHONE#1 11( �q EXT. APN# V LAND USE APPLICATION# I J J (C)v C) I�Q01 PHONE#2 EXT. BOS DISTRICTLOCATION CODE ( ) CONT1 RACTOR/ SERVICE REQUESTOR REQUESTOR w q 1" ,n, I1C R (t V 1 CHECK If BILLING ADDRESS BUSINESS NAME \1 V PHONE# EXT. Rcieln t'l I n { Ma✓k.eF— ao C:5uS-Au HOME or MAILING ADDRESS L FAX# _� C T1 ( ) CITY STATE ZIP BILLING ACKNO LEDGEMENT: 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: PI-) - (� r v )//--) VIA- DATE: 1 1 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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. PAx TYPE OF SERVICE REQUESTED: , COV\GvA. V- v� 9 T COMMENTS: D C�filv�v� C�wv�,Qiti2�L � . NOV v, 2018 SAN dOAVIF?QUlN C H� LTH O PAR MUNry AII ACCEPTED BY: I V `o Q VA 0 EMPLOYEE#: DATE: II ASSIGNED TO: U Y� V/n EMPLOYEE#: DATE: Date Service Completed (if already vclompleted): SERVICE CODE: I P/E: It C),Z Fee Amount: ci 1 cJ2 L-•� Amount Paid 2— Payment Date I ( �7 Payment Type Invoice# Check# T Received By: l fJ EHD 48-02-025 SR FORM(Golden Rod) 07/17/08