COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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• SERVICE REQUEST 0 pe of Busi s or Property PER/ REQUESTOR BILLING PARTY GlJF�` C�-oC_d FACILITY ID # BUSINESS NAME , D i c U v Com/ /� ' SERVICE REQUEST # OPERATOR O MAILING ADDRESS 0 * F BILLING PARTY CILITY NAME � ASSIGNED TO: E ADDRESS � ''j c �{O( Street Number erection may " r Street Name Type Suite # iling Address (If Different from Site Address/ t� SERVICE CODE: ( Y r j rcL.q�T ZIP �#1 � r l �,�,,✓ EXT.I—APN Ll j'/i � /VVl�1 � # LAND USE APPLICATION # )NE #2 EXT. —( ;� ' 0 C 2 BOS DISTRICT LOCATION CODE V CONTRACTOR I SERVICE REQUESTOR 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 DIVISION hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared the p 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. J / I ' �J C� �f APPLICANT SIGNATURE: t+� �' - ' V DATE: ' / / PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPuCANT is not the BILLING PARTY proof of authorization to sign is required 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, r.otechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as t is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: I PA.yWIZ. N RRems1r'F!1 !r APR 2 2 1' sAN JQAUUIlq t. t, : ; PUBUC HEALTH SEFvii;E, 'NVIRONMENTAL HEAI T., i)I`, 15, INSPECTOR'S SIGNATURE: REQUESTOR BILLING PARTY GlJF�` C�-oC_d BUSINESS NAME , D i c U v Com/ /� ' PHONE # /� EXT. / r 'f' � -7 MAILING ADDRESS 0 * F I DATE_ Ll CITY 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 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared the p 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. J / I ' �J C� �f APPLICANT SIGNATURE: t+� �' - ' V DATE: ' / / PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPuCANT is not the BILLING PARTY proof of authorization to sign is required 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, r.otechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as t is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: I PA.yWIZ. N RRems1r'F!1 !r APR 2 2 1' sAN JQAUUIlq t. t, : ; PUBUC HEALTH SEFvii;E, 'NVIRONMENTAL HEAI T., i)I`, 15, INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPPROVED BY: �. v,�� EMPLOYEE #: Doo I DATE_ Ll 2- ..'1 ASSIGNED TO: EMPLOYEE #:DATE: (` �13 Date Service Completed ' alr ady completed): SERVICE CODE: ( P 1 E: 3�g Fee Amount: Do Amount Paid 3C.� Payment Date Payment Type Invoice # I Check # 3 7 S Received By: