COMPLIANCE INFO 1994 - 2010 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN )LINTY ENVIRONMENTAL HEALTF EPARTMENT SERVICE REQUEST Type of Business or Property U a�i �—�� _ i� i tl r ►�)dA FACILITY ID # EXT. SERVICE REQUEST # OWNER /OPERATOR ',1 �L �� t AGI+N !� }�& �{ X i CHECK If BILLING ADDRESS ❑ FACILITY NAME �`•� �Q J 1�� 1 C 1%� 1� SITE ADDRESS Street Number Direction Street Name �OAOv1N NTALiY 5A ENVIFON p,RTME� citv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number HEpITN oEP Street Name CITY STATE ZIP PHONE#1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (5�-> 1 4,�,( � ( 14 N jr j CHECK if BILLING ADDRESS ❑ BUSINESS NAMEPHONE# F�C-�� 4�irc � EXT. HOME Or MAILING ADDRESS 9 ov1' 42WI\E E % I1 � +t I` (Ax# ) CITY 1 I STATE �� ZIP 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. 1 Jn APPLICANT'S SIGNATURE: %k(w ctC avw DATE: PROPERTY / BUSINESS OWNER El 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 ava;�lA} 4-d at the same time it is provided to me or my representative. ^AYC.1vF�l✓\/E� TYPE OF SERVICE REQUESTED: Cj� p04 COMMENTS: CII �OAOv1N NTALiY 5A ENVIFON p,RTME� HEpITN oEP ACCEPTED BY: — EMPLOYEE #: /J DATE: �� a <` ASSIGNED TO:Q��tti /r 271 EMPLOYEE #: j DATE: Date Service Completed (if already completed): SERVICE CODE: S P 1 E: r3 ree Amount: 7 CAmountPaid �2'�q p 0 Payment Date 3ment Type ✓ Invoice # Check # I Lf Received By EHD 48-02-025 REVISED 11/17/2003 �S� �� SR FORM (Golden Rod)