COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUOOUNTY ENVIRONMENTAL HEALTOEPARTMENT SERVICE REQUEST , of Business or Property FACILITY ID # PHONE# EXT. SERVICE REQUEST # FAx # l ) FA 000 3S�(g < o �' z� MN cod>3 h OFA Fi��Tq� NAY M ACCEPTED BY:i G IER / OPERATO � L� �"� I � _ S LLL �(�CfYI CHECK If BILLING ADDRESS TY NAME ASSIGNED TO: EMPLOYEE #: 4DDRESS a4�Ll Date Service Completed (if already completed): Fl?-.QNl�1 C dAlmr P! E: 3 Fee Amount: Amount Paid , ��cS.Oz) Street Number Direction Invoice # Street Name Check # 1 1 Cit Zip Code or MAILING ADDRESS (If Different from Site Address) Street Number Street Name STATE ZIP #� EXT• a-3oss asses APN #/ 1 7 O .� LAND USE APPLICATION # E #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR UESTOR CHECK if BILLING ADDRESS tom} ( �L.GI..Z�. M�� ✓ NESS NAME PHONE# EXT. E or MAILING ADDRESS FAx # l ) STATE ZIP LING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, .owledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project :tivity will be billed to me or my business as identified on this form. o certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN NTY Ordinance Codes, Stan rds, S A n FEDERAL laws. 'LICANT'S SIGNATURE: I--� DATE: ?ERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER 117 OTHER AUTHORIZED AGENT ❑ IfAPPLIcANT is not the B1LLINGPARTY, proof of authorization to sign is required Title FHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the ,e site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment -oration to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is ided to me or my representative. 10 A TYPE OF SERVICE REQUESTED: 4 T M COMMENTS: SqN ✓4AI tiF,g4 q MN cod>3 h OFA Fi��Tq� NAY M ACCEPTED BY:i G EMPLOYEE #: DATE: //7 [' ` > t ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): 14 SERVICE CODE: �' P! E: 3 Fee Amount: Amount Paid , ��cS.Oz) Payment Date 1215 13 Payment Type �' Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)