COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

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SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # R.ETAtL c,&SO Lr&LE RECEIVEEIVE BUSINESS NAME OWNERI OPERATOR BILLING PARTY ❑ fcN�EL �4vt�«1�.�E.z LT rtiLEErZr�C( 1:74C, FActurf NAME 914 1=2EM0KT S µELL MAILING ADDRESS SITE ADDRESS d E R w+ F E O t4 - -F ?� 0 K 1025— T�T 9f4 r StreetNumbw Wrecton �M NameSuke zip q S-6 `i l EMPLOYEE #: —7_3 6 Mailing Address (If Different from Site Address) Date Service Completed (if already completed): SERVICECODE: CITY STATE zip PHONE 1X1 EXT. APN # LAND USE APPLICATION # (-40 CO 9K i - gL 3 Q - e g-, PHONE #2 EXT. BOS,DISTR= LOCATION CODE: CONTRACTOR/ SERVICE REQUESTOR REOUESTOR 'iZ E S i f tiC S T- A, t; [ a-T"io r.( BL UNG PARTY 19( 1� W I C u A- E L w A L TO 9 RECEIVEEIVE BUSINESS NAME PHONE # FXT. LT rtiLEErZr�C( 1:74C, MAY 6 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL 914 "4- - V S -2 - MAILING ADDRESS INSPECTORS SIGNATURE: FAX # ?� 0 K 1025— 9f4 33-3 CITY 1— T- A,. C Q b- k- t t.� 0 STATE C A zip q S-6 `i l BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsION 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 Ordinanco Codes, Standards, STATE and FEDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER 0 OPERATOR/ WNAGER 0 OTHER AUTHmzED AGENT t _ _ co "'r /Z IfApmxcwr is not the BUMP proof of authorfz2don to sign Is rvqufrvd Title AUTHORIZATION 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OlvlsioN as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: P L A- wd 'iZ E S i f tiC S T- A, t; [ a-T"io r.( COMMENTS:PAYMENT RECEIVEEIVE 2 � r V MAY 6 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL (� HEALTH DEPARTMENT INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: APPROVED BY:. C L t `J E-- EMPLOYEE #: C .� 2_4 DATE: 5- ASSiGNEDTO: EMPLOYEE #: —7_3 DATE: S-/ {& Date Service Completed (if already completed): SERVICECODE: , 3 PIE: �3 03 Fee Amount: -1 c.t 1-- -7-7 Amount Paid 4 3 Payment Date 4 I0 ��a Payment Type Invoice #' Check #l� Received By: