COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUOT BOUNTY ENVL'tONMIENTAL HEALTr-EPARTMENT SERVICE REQUEST Type of Business or Property Tim Hempleman FACILITY ID # sail CHECK If BILLING ADDRESS® SERVICE REQUEST # �54Ae62-(0 OWNER / OPERATOR J n�� / �, sy/Jfr CHECK If BILLING ADDRESS FACILITY NAME Almond Blossom Estates 11749 Sawyer Ave SITEADDRESS 1901 Street Number Direction E Yosemite I Street Name Cm Manteca city 95336 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Amount Paid Street Name CITY Payment Type �� STATE ZIP PHONE #t En. APN # LAND USE APPLICATION # PRONE #Z ( I Ezf. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Tim Hempleman COMMENTS: CHECK If BILLING ADDRESS® BuslNEssNAME Hempleman's Pool Cures J n�� / P# 209 E> . 614-6385 HOME or MAILING ADDRESS 11749 Sawyer Ave EMPLOYEE #: / „ f 3 FAX# ( 209 I 847-3305 Cm Oakdale STATE CA ZIP 95361 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 qty will be billed to me or my business as identified on this form. f;;;Eertify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN lydinance Codes, Standards, STATE and FEDERAL laws. ArPPM&NTIS SIGNATURE: DATE: 12-15-2010 P/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor 41C-0211111 If APPLICANT is Not the BILLING PARTY proof of authorization to sign is required Title AIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abto,AWW address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infICSOM 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: VGB Compliance COMMENTS: PAYMENT RECEIVED MAY 2 6 2011 SAN JOAQUIN COUNTY HENVIRONMENTAL ACCEPTED BY: J n�� / EMPLOYEE M qo yg 1'Z DATE: ASSIGNED TO: f2eJ3 4-7 a EMPLOYEE #: / „ f 3 DATE: Date Service Completed (if already completed): SERVICECODE: 5 -2 -2 --PIE: 3(.62— Fee Amount: 2 - _ Amount Paid l{ li Payment Date s 2% 1 Payment Type �� Invoice # Check # Received y: