COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

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SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST / OWNER/OPERATOR ,/ l / BILLING PARTY❑ FACILITY NAME E ADDRESS Vapy/i �/ J Y,,/Strut Numbr Oinction /D GtC �Name 1YP� Seib 8 Mailing Address (If Different from Site Address) CITY STATE ZIP S3 ?C- PHONE#1 ET• APN# LAND USE APPLICATION# PHONE#2 BOS DwRIcr LOCATION CODE CONTRACTOR!SERVICE REQUESTOR REQUESTOR BILLING PARTY❑ BUSINESS NAME / / PHON 2 MAILING ADDRESS �✓7! Sal � � / FAX# CITY GJUG� .I �S GS STATE ZIP t BILLING ACKNOWLEDGEMENT: I,the Undersigned property or business ownw,operator or authorized agent of same,acknowledge that a0 site andlor project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activ4i will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ifAPPMANr is not fhe BLLMproof of audwindon to sign is requ6td 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 tesufts,geotechnical data and/or efrAronmentaftte assessment inbmadm to the SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: PAYMENT APR 2 71 j,y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION INSPECTOR'S SIGNATURE:/ CONTRACTOR'S SIGNATURE: APPROVED BY: EaPI. rmt DATE: ASSIGNED TO: EMPLOYEE#: v= DATE: j Date Service Completed (if already completed): SEtancsCooE: .. 'PIE:. Fee Amount Amount Paid Pay Payment Type Invoice# Check# Received By: