COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

Home Browse Search

SAN JOAQ0 COUNTY ENVIRONMENTAL HEA 61 DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # r 0oo BUSINESS NAME W nA eopsj-f-oc'-�-)5 5 A un /t SERVICE REQUEST # 00 �3 ++6 -A OWNER/ O ERATOR �n�ve� • �� Cwt; r►�i '56 CHECK If BILLING ADDRESS❑ FACILRY NAME L L NL r l' TE 300 SITE ADDRESS Number Dlrectlon C©m 1 •( I0 r Or , / Street Name W C�C�3 FTNCityZJI Oode10 �Street HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. c , APN # ��► 1�-0U5 LAND USE APPLICATION # PHONE #T EXT c , BOS DISTRICT LOC ATION CODE CONTRACTOR / SERVICE RE, QUESTOR I , REQUESTOR �J Ij erq,— 'DeA/ l C_. -J CHECK if BILLING ADDRE55 BUSINESS NAME W nA eopsj-f-oc'-�-)5 5 A un /t COMMENTS: �<11 �fU i 1t7b k 07 P oc� _ / EXT. HOME Or MAILIN Dpf�ESS r �t ��' /v f k l rG/�) (1z y- ) ^ 96 ) 5S q l CITY I j STATE ZIP �1 ), BILLING ACKNOWLEDGEMENT: I, (lie undersigned property or business owner, operator or authorized agent or same, acknowledge that all site and/or project specific ENVIRONMENTAL I-iEALTii DEPARTMENT 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Cortes, Standards, STAT' d : EI laws. 1 APPLICANT'S SIGNATURE: DATE: "�` a3 PROPERTY / BUSINESS OWNER ❑ O EI T It / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTI-IORIZA"PION TO RELEASE, INFORMATION: When applicable, 1, 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/sitc assessment information to the SAN JOAQUIN COUN'rY ENVIRONMENTAL HEALTfI DEPAR'rMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: U COMMENTS: �<11 �fU i 1t7b k 07 RECEIVED APR 1 1 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HE APPROVED BY: EMPLOYEE -I, DATE: ✓ 13 ASSIGNED TO: EMPLOYEE #: 3 YO Date Service Completed (if already completed): SERVICE CODE: Iq LP I E: 3 r Fee Amount: 1V2Amount Paid . Payment Date ,(./ Payment Type Invoice # Check # Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02