COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQti �OUNTY ENVIRONMENTAL HEALT EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING A0DRE5SL1 SERVICE REQUESTS#/ o G (�1 6 1 OWNER / OPERATOR JUN 2 2 2012 CHECK If BILLING ADDRESS FACILITY NAME , PHONE# EaT. SITE ADDRESS Street Number Direction t. Street Str et NaNama C Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Stre¢t Number O N DATE: CITY STATE ZIP PHONE#1 En.APN# ( ) ZI�" S Amount Paid LAND USE APPLICATION III PHONE#2 En. -Z'S BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING A0DRE5SL1 /�- JUN 2 2 2012 BUSINESS NAME 4AN JOAOUN COUNTY PHONE# EaT. HEALTH DEPARTMENT ACCEPTED BY: HOME Or MAILING ADDRESS DATE: / ASSIGNED TO: Z/1 O N DATE: (FId ) CITY STATE ZI�" S 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, Standar s, STATE and FERE laws. c7 APPLICANT'S SIGNATURE: DATE://� O — PROPERTY/ BUSINESS OWNER❑ TOR /MANAGER ❑ OTHER AUTHORIZED AGENT oc/G If APPLICANT is noF6e 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 the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: REf""NED JUN 2 2 2012 4AN JOAOUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: / ASSIGNED TO: Z/1 EMPLOYEE M DATE: Date Service Completed (if already completed): r SERVICE CODE: �j 2 PIE: Fee Amount: !f7c Amount Paid DLI -11 Payment Date U, -Z'S Payment Type ��(_ __ Invoice # Check # Received BI ti� & tia A EHD 02 REVISE17/2003 �11 I ( C Icy 1 i -, SR FORM (Golden Rod)