COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n�I ID SERVICE REQUEST YY Type of Business or Property FACILITY ID# SERVICE REQUEST# TA,0� SS`-ISR 00\g3 3: OWNER/OPERATO CHECK It BILDNG ADDRESS FACILITY NAME SITE ADDRESS I L I I _ I 1 n I e 11112 A__n '; n f1 Cin , 1 OI sz) Street Number 1/\/ �1 u G P/UrLtreet'1N'avmee �G 'IP 7t I/��' Zip Code HOME or MAILING ADDRESS (If Different from Site Address) �,1, L pl , ,` V1 e�• (n 1 1` I L I�r vl 15treet Number V 7 eel Name 170 T CITY �`_.� ,1 STATE CA Zip /J( S-1 ^� r—_I: 7T• APN# L.AND USE APPLICATION# " ( (NEXT• BOS DISTRICT CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE r�2— Hap! M i NG R SFAX# ( ) CITY m STATE ZIP 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. 1 also certify that I have prepared this application and that the work to be f, ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,ST E�and FEDERAL laws. APPLICANT'S SIGNATURE: V�(J(�/ 6 LQ�^�` — DATE: C%C/� � r aO 2O- PROPERTY/ O"PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTtIORIZED AGENT❑ IfAPPL/CANT 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 time it Is provided to me or my representative. 11 /MEN TYPE OF SERVICE REQUESTED: I W UAW0 p�Y�I 'clvED COMMENTS: 1^ ut;r 01 ?010 CUIGL l�� I�� OVvrvu¢ s SAN JOAQUIN H H pEEIVWROpgR Hry ACCEPTED BY: n/1 EMPLOYEE#: DATE: ASSIGNED TO: I Y 1 F Y EMPLOYEE#: DATE: Date Service Completed (B already completed): SERVICE CODE: oW PIE: I(0U2 Fee Amount: 1S2 Amount Paid �' a Payment Date I lot / 2 t7 Payment Type Invoice# Check# G Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003