COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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SAN JOAQ vOUNTY ENVIRONMENTAL HEALTH W ARTMENT Type of Business or Property FACILITY ID # COMMENTS: X _ O -F a� �° l c e l REQUEST c_i`iV i--A,N`lEN4ii 141-77 — CJS eec) Ilee Dzle /' a C? 6VI4, ;SERVICE ACCEPTED BY: �a• V vL c, EMPLOYEE #: {J t _ f DATE: f OWNER/ OPERATOR ASSIGNED TO: �- V`u CK If BILLING ADDRESS FACILITY NAME 4— e S1724F —300 r SITE ADDRESS PIE: / Pa went Date= y ( a Payment Type C � � Street Number Dir coon Street Name City Z112 Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE 2:IP PHONE #1 EXT. APN # LAND USE APPLICATION # ( PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE O. REQUESTOR •;� j� / ) � r/ CHECK If BILLING ADDRESS BUSINESS NAME r� PHONE# � ExT. .m> HOME or MAILING ADDRESS® FAX# ) CITY . f % 7 STATE zip �� BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:_ PROPERTY/ BUSINESS OWNER® OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT If APPLICANT is not the BILLLVG PARTY, proof of authorization to 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the�satne`t ii it `Is. provided to me or my representative, I ' TYPE OF SERVICE REQUESTED: COMMENTS: X _ O -F a� �° l c e l AN ' ` ")i)I:! CJI. c_i`iV i--A,N`lEN4ii 141-77 — CJS eec) Ilee Dzle /' a C? 6VI4, ACCEPTED BY: �a• V vL c, EMPLOYEE #: {J t _ f DATE: f ASSIGNED TO: �- V`u EMPLOYEE #: 2 l� DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid 3I,.�.c)17 Pa went Date= y ( a Payment Type C � � Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11117/2003