COMPLIANCE INFO_2007-2013 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN fOUNTY ENVIRONMENTAL HEALTHVPARTMENT SERVICE REQUEST Type of Business or Property y�� t �% FACILITY ID # SERVICE REQUEST # Qz�at\ Cp�� I QM15n� -793 �j200 5-3e J� OWNER / OPERATOR HOME or MAILING ADDRES CHECK if BILLING ADDRESS ❑ FAX # FACILITY NAME CITY t (rC Y�0 rIZATE Zip q 51 SITE AD�}DRESSS �f O G ��`} ;� DATE: p �r 0 c OI 1 Street Number Direction Street Name DATE: t ,3 6-9- Date Service Completed (if 41readycompleted): Zi Code HOME Or MAILING ADDRESS (if Different from Site Address) /160 QStreet Number Street Name CIN e u E Lte— Invoice # STATE ZIP EXT. PHONE #1 APN # LAND USE APPLICATION # i) u1 d16�p (qb Z 2-c�zo- ?i PHONE #2 EXT. BOS DISTRICT LOCATION CODE Alb) � A -o-- I CONT-111AC'.TOR / SERVICE REOUESTOR REQUESTOR ` y�� t �% CHECK if BILLING ADDRESS \ � 1 BUSINESS NAME Wa(<Jkb) PHONE# EXT. (C ---lb �1b� HOME or MAILING ADDRES _ -UL d FNV/tj UlN FAX # COVN ry yFALTy pq� CITY t (rC Y�0 rIZATE Zip q 51 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, Standards, STATE and FEDERAL laws. ( , APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT 0 5t- D"c,e— If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tide 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. TYPE OF SERVICE REQUESTED: �S 1— y�� t �% M RE ENT COMMENTS: � 1 // �f Irk 7 1 U _ -UL d FNV/tj UlN COVN ry yFALTy pq� p ��M' ACCEPTED BY: (�t C EMPLOYEE #: 3-Z DATE: p ASSIGNED TO: 14 1✓ N Q EMPLOYEE #: �(D ` Z DATE: t ,3 6-9- Date Service Completed (if 41readycompleted): SERVICE CODE: /160 P/E: 7'3oS' Fee Amount: �� pv Amount Paid R o L? Payment Date 3 /U cF' Payment Type e u E Lte— Invoice # Check # ?-- p S-5- Received By: EHD 48-02-025 V S I Y lT SR FORM (Golden Rod) REVISED 11/17/2003