COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQU COUNTY ENVIRONMENTAL HEALTF 7,PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# PERVICE REQUEST# ' 010 Wo oc� OWNER OPERATORr ( �rke I Q I �r CHECK It BILLING ADDRESS FAciuTY NAME 1---� r The Pr;x SITE ADDRESS l.h(11 ON Pa 75-7ZO IS6-4e �' JW !% Iltunber Direction I Street) Name city 23D Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Name CITY STATE LP L 5� P PHONE#1 EKT• APN# LAND USE APPLICATION• Utcjj ) 329-7839 PHONE#2 Err. BOB DISTRICT LOCATION CODE ( ,kq ) 3V-Z4SZ 1 11 CONTRACTOR/ SERVICE RE UESTOR REOUEl TO` L e r/-( CHECK ff BILLING ADDRESS (In 'Or bn USINiEss NIME PHONE# 20-25gT-q-' ExT- I Y1!5 US- [6 - (1443(l HOME Or MAILING ADDRESS FAx# S05,77 } (20 )545 25 CITY < STATE LP 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 we 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,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: � i/C�Y, AaShhofnL� DATE: PROPERTY/BUSINess OWNER❑ OPERATOR/MANAGER K OTHER AUTHORIZED AGENT❑ ifAPPLICANT is not the BiLL/NG PAR TP 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. PA ,, nir EQU TYPE OF SERVICE RESTED: yp—ec- 6!;� EDEI ED CoMMENrs:(I) Nyyo 6 l canoe Fe5oMd (b(��l&S �I/S fro 3 /)etu fi(e/frim pCdl6pcOCT — 6 2011 idrm cmcre}e I ®con YWC CV 6clnaf I (6) r`)eW 9OLW/c6J P31S"JOAQ o n POWOr It146H , ® Y1eW wln;}Q �Iqs}e 1r. HREA EALTN DEPAc, A. R ,, I c fe mode ACCEPTED B EMPLOYEE#: / DATE: Q 1 ASSIGNEDTO: t EMPLOYEE#: 6'Z DATE: Date Service Completed (N already Completed): SERVICE CODE: P 1 E: Fee Amount: l "Z Amount Paid Payment Date b ) 6 C Payment Type Ll--' Invoice# Check# [Q3 Reeelved By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003 (� ,a I ZSa�O P lam cV1eC�� fee.