COMPLIANCE INFO_2004-2008 - Laserfiche WebLink

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t:_eNAN JOAQIJI tIN, I'Y.L'NVIRONMEN'FA'L•IIEALTIWI'Al.t'rMENT' ICE REQUEST rt Type of Business orT'Z�' FACILITY ID # SERVICE REQUEST # aw Glcf BustclES.s,NAME 1 0 r. o f � SAN JOAQUIN COUNTY O ER /OPE R HOME Or MAILING ADDRESS ACCEPTED BY: I KKS 3 a c_ DATE: CHECK if BILLING ADDRES FAC NAME ,n ; t) 1) 3 iu 5— 15,y 3 ' SERVICE CODE: C STYE ZIP SiT ADDRESS �c - C F < � L � <— Invoice # Check #` Street Number iri rectionS reef Name C' Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CIN STATE ZIP PHONE #1T ( ) APN # LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUEST � O (O 1 ' v COMMENTS: CHECK If BILLING ADDRESS BustclES.s,NAME 1 0 r. o f � SAN JOAQUIN COUNTY PHONE # o EXT.-- C HOME Or MAILING ADDRESS ACCEPTED BY: FAX # DATE: °-F t 0 l<c le � n L� h z#% EMPLOYEE #: t) 1) 3 iu 5— 15,y 3 CITY C' SERVICE CODE: C STYE ZIP Amount Paid �c - C F < � L � <— 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, Standar", TATE and FEDERAL laws. X/ APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER P OTHER AuniORIZED AGENT ❑ 1f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title OP 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. W\Y IM, PA i. TYPE OF SERVICE REQUESTED: R E C'E= i %/ E G COMMENTS: OCT 8 2004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: C P I E: Fee Amount: Amount Paid �c - Payment ateIB Payment Type Invoice # Check #` Received 6W. EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden R,