COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

Home Browse Search

SAN JOAQU*OUNTY ENVIRONMENTAL HEALOPEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # FrA c 3 SERVICE REQUEST # J 00 3 -14 OWNER/ O ERATOR rCHECK cc� 4 1 b r i EMPLOYEE #: If BILLING ADDRESS FACILITY NAME LLNT_ IE 300 ASSIGNED TO: EMPLOYEE #: SITE ADDRESS Street Number Direction Date Service Completed (if already completed): f Street Name W P I E: 2 3 "tCitv Zip CodeO HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Payment Date A� ��_ I Street Name CITY Check #� STATE ZIP PHONE #1 EXT. c ) APN # ` S 1` q- o u 5 LAND USE APPLICATION # PHONE #Z EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR h f::� _0 VJ �1 " -+1" 1 l;�t CHECK if BILLING ADDRESS BUSINESS NAME _1 n ` / �� ` w , f " ry `� ✓ PyQ EXT. HOME Or MAILINGDp�R1ESS 101-1 :, EMPLOYEE #: CITY �� l STATE ZIP Pit 7fo BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTALI-IEALTII DEPARI'MENThourly 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, STA•I' d�'Ik�Alaws�, 1 APPLICANT'S SIGNATURE: DATr: PROPFRTY/ BUSINESS OWNER❑ O EI T R/ MANAGER ❑ OTHER AUTHoRizFD AGFNT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tide 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: v (, PAYMENT COMMENTS: 0 b0 hilt / � r ` ) wi 6�tS�o l vA 2003 SAN J AdUIN CO UNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPROVED BY: EMPLOYEE #: �Z� � DATE: 4 ✓ f i —3 ASSIGNED TO: EMPLOYEE #: 3 Q DATE: q Date Service Completed (if already completed): SERVICE CODE: L�� P I E: 2 3 Fee Amount: I((7 Amount Paid (1 � Payment Date A� ��_ I Payment Type Invoice # Check #� Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02