COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

From:946 388 2001 04/19/2013 10:50 #422 P.002/004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Eo A SERVICE REQUEST # {w� I IT 1 ,4p'IOA ci-c(> OWNER/ OPERATOR ACCEPTED BY: CHECK N BILLING ADDRESS FACILITY NAME r ^, c - DATE; [f )G) ) ASSIGNED TO: SIT AtD�.D'R%,ESS I EMPLOYEE#: 2- DATE: Date Service Completed completed): —1 ,.1D Sbaat Number oinCtioftzip PIE: 36 O "�-- Fee Amount: ��^� Code HOME Or MAILING ADDRESS (N Different from Site Address) /y Payment Type lir Invoice If Stmel Number Cheek # �� /z Street Na.. CITY STATE LP PHONE #1 APN # /, LAND USE APPLICATION C (W))LN 1�^01U� 06z(—) PHONE#2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOI� QX �I CHECK If BILLING ADDRESS BUSINESS :'TAME ^ r� /`'(_(.� PHONE# Ems' HOME Or MAILING ADDRESS FAx# -1 • A ( (to) 3 e ( CITY Crt �Q�,� t STATE CA LP S flZ BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator o authp m—t gent 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 i accordance with aI1 SAN J)AQUIN COUNTY Ordinance Codes, Stand5ERATOR TATE and FEDERAL la APPLICANT'S SIGNATURFre DATE: ��& PROPERTY/ BUSINESS OWNER 11/MANAGER ❑ OTHER AIRHOR=n AGENT CIS 0"APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 thISAa a time it is provided to me or my representative. 41 MfNT TYPE OF SERVICE REQUESTED: Eo A COMMENTS: IT 1 ,4p'IOA ACCEPTED BY: lVfi•'(rYL� EMPLOYEEM DATE; [f )G) ) ASSIGNED TO: V( `w(if alalready EMPLOYEE#: 2- DATE: Date Service Completed completed): SERVICE CODE:S, ZZ PIE: 36 O "�-- Fee Amount: ��^� Amount Paid -J'd D Payment Date /y Payment Type lir Invoice If Cheek # �� /z Received By: EHD 48-02-025 REVISED 11/172003 Received Tlme Apr. 19, 2013 10:47AM No.2887 SR FORM (Golden Rod)