COMPLIANCE INFO 2005 - 2009 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REOUEST Type of Business or Property FACILITY ID # � SERVICE REQUEST # L- F v F- CHECK if BILLING ADDRESS S 20 O S a--1 PHONE # E�- HOME or MAILING ADDRESS P,0. 3ox (02!r- OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ BILL t Cp.-rNl� NOIiQ CITY A- -0 FACILITY NAME o S k L 4 SITE ADDRESS S T O C !L T 0.` 2 t S 3 / Street Number Direction Street Name city Mod. N� HOME or MAILING ADDRESS (If Different from Site Address) DATE: SA E Street Number Street Name CITY STATE ZIP. PHONE #t EXT.APN # LAND USE APPLICATION # .. -;i SERVICE CODE: (Gj PHONE #2 ExT. BOS DISTRICT LOCATION CODE Cn1VTR ACTOR TOR / ,9F.RVICE REOUESTOR 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, ST TE d F E laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT r R A<," IfAPPL/CANT is not theB/LLINGPARIY, 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 :AoA tme nr my representative_ yi vvau...+... ..... ... ...� --r------------ TYPE OF SERVICE REQUESTED: 1P L A-t.I, 2 E V t rpw S u S%U � REQUESTOR '^ ( C 0 /t 'tr ,r I t (� �'�e V l Ct 7T Y/ V �/1/ RG0E--1�/E0 CHECK if BILLING ADDRESS BUSINESS NAME 1 �lAL-r014 E/�(�IF4EE P K4C, r �ijQ r _ PHONE # E�- HOME or MAILING ADDRESS P,0. 3ox (02!r- FAX # (-?e6 )3-+3- CITY A- -0 STATE C A 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, ST TE d F E laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT r R A<," IfAPPL/CANT is not theB/LLINGPARIY, 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 :AoA tme nr my representative_ yi vvau...+... ..... ... ...� --r------------ TYPE OF SERVICE REQUESTED: 1P L A-t.I, 2 E V t rpw S u S%U COMMENTS: RG0E--1�/E0 /��'��' Y J ( le— MAY 3 n 2007 SAN JOAQUIN r-NVIRNMPN AL rr ACCEPTED BY: , L t U �I EMPLOYEE #:HFA- Z( DATE: /20 01 ASSIGNED TO: To U A K EMPLOYEE #: (, s'S DATE: S 3 G27 Date Service Completed (if already completed): SERVICE CODE: (Gj P ! E: vZ 3 . Fee Amount: 'c Amount Paid Payment Date 5 C � Payment Type / Invoice # Check # 7 Rec ved By: n � '- SR FORM (Golden Rod) REVEHD SED 11/1 Lb x -Gr S 1 jG.�Q� REVISED 11/17/2003