COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

Home Browse Search

. A 0 r--] SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property i I CHECK If BILLING ADDRESS FACILITY ID # PHONE #,y ExT. - '— SERVICE REQUEST # I � Ln awtC- HOME or MAILING ADDRESS �6 I &rn fir. FAx# (Z(1) 34" I DATE: ASSIGNED TO: 2 (f/� OWNER/ OPERATOR fff DATE: r CHECK if BILLING ADDRESS FACILITY NAME SERVICE CODE: _ l o P 1 E: Z 3 � — SITE,ADDRESS Amount Paid 6C par xd c) n J >� . Payment Type z (�fi y-) �� 1� Street Number Direction Street Namei Zi Code HOME or MAILING ADDRESS (If Different from Site Address) i0:306 Street Number Street Name CITY TEziP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2_ ExT• cio& O—`JA)L 4- U LL BOS DISTRICT 11 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR i I CHECK If BILLING ADDRESS BUSINESS NAME IYr�� YS PHONE #,y ExT. - '— c 2 ACCEPTED BY: HOME or MAILING ADDRESS �6 I &rn fir. FAx# (Z(1) 34" CITYSTATE y� zip %3(b 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, Stand ds STATE -and -FEDERAL laws. APPLICANT'SSIGNATQIRE-��_—�'��1+'�— DATE:f-i2 PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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 T T2 M RECF 1V ED COMMENTS: FEB 15 2012 SAN JOAnUVN COUNTY FWRONMENTAL HF1yTH DEPkRTMEW ACCEPTED BY: EMPLOYEE #: r DATE: ASSIGNED TO: 2 (f/� EMPLOYEE#: L4I) 1 ` DATE: r �� Date Service Completed (if already completed): SERVICE CODE: _ l o P 1 E: Z 3 � — Fee Amount:S V Amount Paid 3 S Payment Date l S� 1 Z Payment Type Invoice # Check # rS`� e3 I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11117L=3