COMPLIANCE INFO_2004-2015 - Laserfiche WebLink

Home Browse Search

SAN JOAQUI ' OUNTY ENVIRONMENTAL HEAL -T' DEPARTMENT ` SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # wAsr� PHONE# ) EXT. V/1-&3J7 5�0Lf OWNER/ OPERATOR n r CHECK If BILLING ADDRESS , [I CITY -�-ry c tz--rn N FACILITY NAME /'J o r(- lA l Z- ZIP ISZU S SITE ADDRESS ACCEPTED BY: t /.� jC DATE:n /_ tf �O S-ro-CK I )L( 2— 3 1! Street Number Direction Street Name SERVICE CODE: iq,6 Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Amount Paid _ Payment Date Payment Type ✓ S' Street Number Check # �, = Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (201) 2,56 -4164 b PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /n�p p � 4 11/ t! I I C i L ^� CHECK If BILLING ADDRESS BUSINESS NAM 6 ,r0!`1 0(11) PHONE# ) EXT. V/1-&3J7 HOME or MAILING ADDRESS/� � ,i53 0-)11 6-7 t,�L1�Ltn D12t(J.� FEB - 6 2006 FAX # (zf11) /, 7/�'/` � 72— CITY -�-ry c tz--rn N STATE( ZIP ISZU S BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projects ific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be,billed to met or my bu ess as identified on this form I also certify that I have prepared t is application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stand rds, ST TE and FEDE a APPLICANT'S SIGNATURE: DATE:,: iC PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT --S�a U 1 CC elf NiFa � If APPLICANT 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/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: U �/� 1 (nia ^� COMMENTS: RECEIVED FEB - 6 2006 COUNTY SAENV RONME TH DEPARTMENT ACCEPTED BY: t EMPLOYEE #: film DATE:n /_ tf �O ASSIGNED TO: A I I n ' /I EMPLOYEE #: Z GJ DATE: It—oh Date Service Completed (if already completed): SERVICE CODE: iq,6 P 1 E: 2 3 Fee Amount:�0 Amount Paid _ Payment Date Payment Type ✓ Invoice # Check # �, = Received' By: \ <- EHD 48-02-025 REVISED 11/17/2003 SIR FORM (Golden Rod)