COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

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• SFRVIr'F PrOI FCT 0 Type of Business or Property FACILITY ID # BUSINESS NAME I,t1AoTo� GK c,t-cE�2e..cc, r mac- COMMENTS: SERVICE REQUEST # RE,-rA,IL C:A-So 1,a\4F-- �u 5 T- A-(, C A-!- r a -f 0 t= N r;nn/ 9fe MAILMG ADDRESS � ,D l3oX IOzS- 1 14 1— i s 7"c ),cl. r I L L FAX # 9r6 CITY W _ S At2A, VtA(s".t b STATE � A- ZIP � S� ce' Suv..ps . �EBIB20o4 OWNER/ OPERATOR Q BILLING PARTY 0 tl ((L S T-019YL� F1'(Z IG Filf-S . C ENVIFIONME LYDEP R MENT VA FACILTTY NAME �O CONTRACTORS SIGNATURE:JiA SITE ADDRESS S EMPLOYEE #: DATE: (211111q 1 Q(( V F ASSIGNED T0: r�Lh1 csan EMPLOYEE #: DATE: / © 3 o Street Number oiredon SUW Nine 7TT. TypeSuke Fee Amoun . G Mailing Address (If Different from Site Address) Payme t Date d/ S 6 r E':'z P n- s r, S T_ Invoice #' Crit wto•� STATE ZIP C Ac �/' /S3 � PHONE #1T• APN # LAND USE APPLICATION # (100 Sro - 6 r4- Fs -Co PHONE #2 7�� TRICT LOCATION CODE' CONTRACTOR/ SERVICE REQUESTOR REQUESTOR t C � � WA c. To ►-( Y ,PHONE BILLING PARTYX BUSINESS NAME I,t1AoTo� GK c,t-cE�2e..cc, r mac- COMMENTS: # EST. -3:�3-ftsz. �u 5 T- A-(, C A-!- r a -f 0 t= N r;nn/ 9fe MAILMG ADDRESS � ,D l3oX IOzS- 1 14 1— i s 7"c ),cl. r I L L FAX # 9r6 CITY W _ S At2A, VtA(s".t b STATE � A- ZIP � S� ce' BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedric PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 FEDERAL laws. I APPLICANT SIGNATURE: that the work to be perform will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and I DATE. 1- ! t �— Q c� PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT -t C n o -C T -d a— IfAPvt.C.wr is not tha 811 rro PAmv proof of iuthorizidon to sign Is requGod Title AUTHORIZATION TORE LEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above sito address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTIi 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: �u 5 T- A-(, C A-!- r a -f 0 t= N r;nn/ S Pi L t_ c 0 � c �( Fin S A--" rZ o to 1 14 1— i s 7"c ),cl. r I L L S v PIA P C . RECEIVED nc� ozs trrLC Suv..ps . �EBIB20o4 SAN JOAOUIN COUNV 401 -VA ENVIFIONME LYDEP R MENT VA INSPECTOR'S INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE:JiA APPROVED BY:. EMPLOYEE #: DATE: (211111q 1 2 ASSIGNED T0: r�Lh1 csan EMPLOYEE #: DATE: Date Service Completed (if alrea"111 y completed): CECODE: P / E: Fee Amoun . G Amount Paid ��!/ Payme t Date Payment T c Invoice #' Check # 3 Received By: