COMPLIANCE INFO_TERI EISERT - Laserfiche WebLink

Home Browse Search

I SAN JOAQUIN(:OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# ,OWNER/.OPERATQR CHECK If BILLING ADDRESS N ME—'� Y -TU SITE ADDRE S Street Number Direction let ' ity H M IVIAILI ADD SS (If ff t from Site Address) Street Number Street Name �NCL—bn A Z pg 1 EXT• APN# LYND USE APPLICATION# PHONE#2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR Rt�STOR CHECK If BILLING ADDRESS S NAMB-7— EXT. 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 Phplication and that the ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards S ATE an DERAL Ia APPLICANT'S SIGNATURE: A DATE: (.�1 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT 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 t ime it is provided to me or my representative. Menm. f]' TYPE OF SERVICE REQUESTED: c� r%DI�1Cyc L Q Gtl�'f� COMMENTS: �15 SqN dOAQUI HEq��H p0 q� 1- ENT ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: �1 EMPLOYEE#: DATE: `Z /'� Date Service Completed (if already completed): SERVICE CODE: 1(j� I P I E:.4(Q3 Fee Amou Amount P-" 0?60,U D Payment Date is Payment Type Invoice# Check# Receiv d By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003