COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN *NTY ENVIRONMENTAL HEALTH nFPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICER QUEST # OWNER/ OPERATOR ACCEPTED BY: CHECK If BILLING ADDRESS FACUTYNAME PHONE# E' s'R 9 SITE ADDRESS / 7`(\Q,(�� �0 Street Number Direction O �^^ O O�Y� CC Street Name 1 �, p� Ci 9G`7 7i1 O ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number / Lt fJ 7 Street Name CITY (zOoj STATE ZIP PHONE #1`E'IT• G-1 APN # CC,, i' % - /JPO LAND USE APPLICATION # PHONE #2 EXT. Invoice # BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Y M x Y" COMMENTS: CHECK if BILLING ADDRESS i-' 13 11 7ppy lACJV44UJN c OU ACCEPTED BY: BUSINESS NAME T f1 IQl Q Q\08 Ari EMPLOYEE #: E 3?-( PHONE# E' s'R 9 cs 0\ EMPLOYEE#: �j ({�-7 20 Date Service Completed (if already completed): HOME or MAILING ADDRESS(� SERVICECODE: 5a2- FAx# / Lt fJ 7 (o O kk . �Y\ `y'\ �/ G aZ� (zOoj I CITY ,^ STATE : A 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 I also certify that I have prepared this appy on and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, SrTTiaand FEI�RAL laws. APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER ❑ IfAPPLICANT is not DATES: �t ER ❑ OTHER AUTHORIZED AGENT*r1JL`�- 9of of authorization to sign is require 7wte 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. E_ G 4 E A4c—EI(SX-- 0 C. TYPE OF SERVICE REQUESTED: COMMENTS: 13 11 7ppy lACJV44UJN c OU ACCEPTED BY: D L IUF- t 44A- EMPLOYEE #: E 3?-( DATE: 2 /3 0 p ASSIGNEDTO: ('t -A -1 -.LL/ IF SC -o EMPLOYEE#: �j ({�-7 DATE: f3/6G Date Service Completed (if already completed): SERVICECODE: 5a2- PIE: 5&02 - Fee Amount: �/ G aZ� Amount Paid a` o Payment Date \3 U Payment Type L,,-- Invoice # Check # Received By: M� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1712003