COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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' SERVICE REQUEST Type of Business or Property FACILITY ID# I SERVICE REQUEST OWNER/OPERATOR BILLING PARTY pIF-M a o GPS f l P f� FACILITY NAME SITE ADDRESS ( � _ w 1 CT Coit-2 t�"1 Street Numhr ofrecon Street Name Type Suite 2 Mailing Address (If Different from Site Address) C�Cv--t STATE C LP 5 PHONE#'I ErT• AP► �N't LAND USE APPLICATION n �4�, - lb3�o PHONE#Z Er. BOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR BILLING PARTY❑ BUSINESS NAME l I PHONE# l �T' MAILING ADDRESS 2� m � - I FAX# CITY � — SP17 STATE C� ZIP BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, acknowledge ttiat ail site and/or project specific PuBuc HEALTH SERvicEs ENVIRONMENTAL HEALTH DW*N hourly charges associated with this project or activity will be biped to me or my business as identified on this tear). 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. APPLICANT SIGNATURE: / DATE PROPERTY/BUSINESS OWNER lY OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 9APPrJrAw is not the 8[Lm Purr proof of authormtlon to sign is"end rine AUTHORIZATION TO RELEASE INFORMATION:When appricable,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 environmentallsile assessment information to the SAN JOAQUIN COUNTY Pusuc HEALTH SERVICES ENVIRON&eNTAL HEALTH ONasloN as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ' MOVE v0iti6icn i 5: �"" INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY: E'mpw mrt DATE: ASSIGNED TO: EmpLOYEE#: DATE Date Service Completed (If already completed): SERvtcECODE P!E: Fee Amount Amount Paid Payment Date Payment Type Invoice# —TC—heck# Received By: r 0