COMPLIANCE INFO 2003 - 2008 - Laserfiche WebLink

Home Browse Search

SAN JOAQI COUNTY ENVIRONMENTAL HEALT- ?PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAM �^ • ' ,f ` SERVICE REQUEST # Orl 5�G�1Uf�P�O000a-85 HOME or MAILING ADDRESS (D. a . 15R.o0a0a4I OWNER OPERATOR STATE ZIP CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS ��` �. Lo c 5� Street Number Direction Street Name Cit ZiCode HOME or MAILING ADDRESS (If Different from Site Address) PIE: Fee Amount: �, 0 Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # -oG',5 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR1 �� • CHECK if BILLING ADDRESS BUSINESS NAM �^ • ' ,f ` RECOV'— _ ExT' PHONE #A C HOME or MAILING ADDRESS (D. a . FAx ) CITY O ` �© ['1 STATE ZIP BILLING ACKNOWLEDGEMENT: 1, 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: Ary'v�" _ DATrE:: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Ja CpCC'aC� If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: C.1—"lI A, ) PAYMENT COMMENTS: RECOV'— JAN 13 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP ACCEPTED BY: L, t V Me EMPLOYEE #: 3 f DATE: 6 S ASSIGNED TO: `t1/.%Zl.�LE EMPLOYEE #: 3 S DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: �, 0 Amount Paid Payment Date !v— Payment Type j Invoice # Check # ` Received By EHD 48-02-025 REVISED 11/17/2003 U' SR FORM (Golden Rod)