COMPLIANCE INFO_2001-2008 - Laserfiche WebLink

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SERVICE REQUEST Type bf Business or Property — FACILITY ID # YMI C u 4, E. L �,(/A ATO( SERVICE REQUEST # 1ZE-VA,I (- � as0 Lf m6- BUSINESS NAME AcTo�t �ncc,r�E�rcE�u� C oo �L-3 %00 h L -r OWNER I OPERATOR MAILING ADDRESS P.O. I30 IcZ.5-- BILLING PARTY 00 0 V 1 IL S -r-0 P W A-rL 6! F.�r` S tla z FACILITY NAME Q'r- t 3 Z 1514,6 Ct I SITEADDRESS W. SAN JOAUIN COUNTY A vK P% 64L L _ S SS Street Number Direction Street Name TYDe SvNe/ Mailing Address (If Different from Site Address) APP ROVEDQY:. N S 6 E S q— S -r a 64"t— EMPLOYEE 9: ��,� j CfTY r r2EWt0K 't" ASSIGNED TO: STATE ZIP c 41- 38 PHONE #1T• DATE: APN # LAND USE APPLICATION # Fr s -c 0 Fee Amount:`1-1-6, Amount Paid Payment Date y PHONE #2 EXT. BOS;DISTRICT LOCATION CODE CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR — SLUNG PARTY YMI C u 4, E. L �,(/A ATO( BUSINESS NAME AcTo�t �ncc,r�E�rcE�u� C PHONE # 1116 -43- tts� MAILING ADDRESS P.O. I30 IcZ.5-- P RECEIVED FAX # 3�3- tla z CRY F 44- C ►i. VK o A v STATE C, A ZIP 1514,6 Ct I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge Viat all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmSIoN 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 Ordinanco Codes, Standards, STATE and FEDERAL laws.] APPLICANT SIGNATURE:DATE: PROPERTY/BUSINESS OWNER O OPERATOR/ MANAGER O OTHER AU owzEDAGENT '6 CC&LTtzA-(.'r`O!L It APPt cmr is not the 8,u m P vrry proof of authorization to sign Is Muirod 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 environmentaltsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH Drvisiw as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: — COMMENTS: P RECEIVED APR 15 2003 SAN JOAUIN COUNTY PUBLICO HEALTH SERVICES HEALTH DIVISION ENVIRONMENTAL INSPECTOR'S SIGNATURE CONTRACTOR'S SIGNATURE: APP ROVEDQY:. EMPLOYEE 9: ��,� j DATE: ASSIGNED TO: _j EMPLOYEE 9:1-J Be- DATE: Date Service Completed (if already completed): SERVICECODE: p f E: Fee Amount:`1-1-6, Amount Paid Payment Date y Payment Type Invoice #' Check # Received By: