COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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0 SERVICE REQUEST EHOO61SR revised 07/10/98 Type of Business or Property [-7 FACILITY ID # BUSINESS NAME .STA N L r --y IJ SERVICE RE UEST, 1 OWNER/ OPERATOR San SOa I - t1,Y1 �t trT BILLING PARTY FACILITY NAME CIS lean 1 O ��O�Q STATE C� ZIP �57�a SITE ADDRESS / D Street Number E . Direction r N4 ze Imo-, Street Name Type Suite# Mailing Address (If Different from Site Address) -- CITY - �iDG�- O✓1 -- $TC- ZIP f 7 PHONE #1 ExT. APN # LAND USE APPLICATION # PHONE #2 ExT. $OS DISTRICT INSPECTOR'S $ G LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR- --17 � A55oG I A7-&.5 ZiAG � BILLING PARTY ❑ BUSINESS NAME .STA N L r --y IJ COMMENTS ❑ PHONE # EXT. PHONE .1/6 &3s 414 or MAILING ADDRESS a X80 S un r•T se✓o� �Llr!n FAX # R/19)looUlyc CIS lean 1 O ��O�Q STATE C� ZIP �57�a BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity will be billed to me or my business as idenWOOPERATOR/ I also certify that I have pron and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, StandardL laws. APPLICANT SIGNATURE: DATE: PROPERTY / BUSINESS OWNER MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY Proof of authorization t0 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 PUBLIC 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: ra I,, � „ _ �r COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER ❑ — —' ---- ---- -----DEC 2 2 1998 -- -----._—. -- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICtS ENVIRONMENTAL HEALTH DTVI r� INSPECTOR'S $ G TU E: �t CONTRACTOR'S SIGNATURE: I DATE: J APPROVED BY: EMPLOYEE M DATE: ASSIGNEDTO: SA S EMPLOYEE#: � � DATE: /-q-'Ra - 7 Date Service Completed (if already complete : SERVICE CODE: G P /f: 304 Fee Amount: °— Amount Paid iwl oi� Payment Date Payment Type Invoice # Check # a Received By: