COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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SAN JOAQAOUNTY ENVIRONMENTAL HEALTH&ARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # EMPLOYEE #: ([. l(E SERVICE REQUEST # HOME or MAILING ADDRESS 84PC o ?- ASSIGNED TO: FAX# 1209') 0CITY , (.--P/ Z —r E P 1 E: Z _�3 Cy Fee Amount: .3 I� Amount PaidOD Payment Date OWNER / OPERATOR Payment Type C CK if BILLING ADDRESS u I Received By: D ® FACILITY NAME . , / T,E D �� SITE ADDRESS I � � s � , _ 9 ,� ^ � � /vfJ •r -s7 d�� ✓CTI �j J••� � / 7 (O Street Number DIrectlon Street Name Zip Cod HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE ##1 APN # LAND USE APPLICATION # /EXT. (6w "j 4 �`V PHONE #2 ExT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /�rI'� CHECK if BILLING ADDRESS BUSINESS NAME% � I'r� /L/ G/V EMPLOYEE #: ([. l(E PHONE# � � Ems' HOME or MAILING ADDRESS 84PC o ?- ASSIGNED TO: FAX# 1209') 0CITY , (.--P/ Z —r 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. G APPLICANT'S SIGNATURE: �/4--- DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT k C Q.48,r 4 fZ-7W 9 If APPS/CANT is not the BILLING 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/,Nt e information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th�A provided to me or my representative. - TYPE OF SERVICE REQUESTED: S F P 1 Z 20h COMMENTS:12 �r�`S T o,� c%r%G�.�i ►v i� s�l GL V ��E �— SAN JOAQUIN CO ENVIRONMENT HFALTH DEPARTM ACCEPTED BY: `�,�-�y' EMPLOYEE #: ([. l(E DATE: ASSIGNED TO: EMPLOYEE #: Lf DATE: �' Date Service Completed (ii already Completed): SERVICE CODE: P 1 E: Z _�3 Cy Fee Amount: .3 I� Amount PaidOD Payment Date Payment Type C Invoice # Check # a-33 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 NTY L .NT