COMPLIANCE INFO_2006-2011 - Laserfiche WebLink

Home Browse Search

s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of BQussi�n—ess or Property FACILITY ID # SERVICE R�E/QUEST(`# 2 q, 1 A -f L- U �l/C,— � 000 a (� C -W -0 0 � T ? rJ 0 OWNER / OPERATOR ❑ V (1 / ® W I/ r C K y, j CHECK If BILLING ADDRESS r - l FACILITY NAME In CITY CITY 2 SITE ADDRESS P / E:'Z 0 z- 0 V i 5 V E- PM A t -LT- 6-C A 9 $— 3 3 6 11 ( & Street Number Direction Invoice # Street Name city Zip Code H�O/ME or MAILING ADDRESS (If Different from Site Address) t.L� (Z (� 2 c S (� S - -+-Street �6 Number Street Name CITY f iz L vti 0 STATE C A ZIP / , 9 r 3 R' 7 �l PHONE #1 ExT• APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT -T OCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Ai UA CHECK If BILLING ADDRESS BUSINESS NAMEPHONE A L �4 r,( �� C� (n( , �( �, c' - # Exr' q,6 3 a- 3 - l I .f' >_ HOME or MAILING ADDRESS ASSIGNED TO: FAX # 0 /0 21' DATE: (916 ) 3:�_3- ?6 - CITY CITY 2 STATE Q A- ZIP 94-6 a r 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 t at the work to be perfo ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA an FED RAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER OPE ATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1.]I C !7"' R Civ 2-- IfAPPLICANT 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. `' . I "AYM ENT r1t IV TYPE OF SERVICE REQUESTED: P C 41) (?/V t t --W S P Zvl ! LL' ` D COMMENTS: MAY 2 S 2 MM 2 � SAN JOAQUIN C 6LTH DEPART EN�11R0 S� �E�tty ACCEPTED BY: EMPLOYEE #: DATE: c'W ASSIGNED TO: EMPLOYEE #:. DATE: Date Service Completed (if already completed): SERVICE CODE: ' P / E:'Z 0 Fee Amount: e ` Amount Paid 115L�. Payment Date Payment Type Invoice # Check # 3 9 -,2p Received By:ZZ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 N LINTY AL ENT