COMPLIANCE INFO_2023 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # r b OWNER / OPERATOR J CHECK if BILLING ADDRESS ❑ FACILITY NAME �J '}� A C + F I SITE ADDRESS ' y Ll -F N <) RT C jV If I) �- � (] S �? Pq 2 Street Number Direction Street Name Cit I ZIP Code HOME or MAILING ADDRESS ( If Different from Site Address ) I .� 4 j C �_ S L Street Number t Street Name CITY STATE ZIP PHONE # 1 EXT . APN # LAND USE APPLICATION # '97 L) PHONE #2 EXT . EMAIL BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME r Iii l AK) CAFE PHONE # EXT ( rA % ) V2 6 1 If Ll HOME or MAILING ADDRESS Ll Y H � b R V� 6 n} IC t) FAX # ( CITY C7 T STATE C an ZIP a L ( � EMAIL Ku LW f) vw% � ) NCs) H 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 . 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 : /� ;' ` __ , DATE : - 2d 23 PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is j�,�3quired 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 HEALTf-! DEPARTMENT '3s soon as It Is available and at the same time It is provided to me or my representative . TYPE OF SERVICE REQUESTED ' RECEIVPM MMLW COMMENTS : PvR 10 2023 SAN JOAQUiIV CpUNTY ONMENTAL DEPARTA4ENT ACCEPTED BY : a ^ -a \,v 01 EMPLOYEE # : DATE , ) %%aaaaatt L0000110 ASSIGNED TO : \ I \ ►`Cj` � �Z� EMPLOYEE # : DATE : Date Service Completed ( if already completed ) : SERVICE CODE : C) ` P / E : Fee Amount : � Q Amount PaidPayment Date /� I o Payment Type Invoice # aaet c 2 2 Received By . r� EHD 48 -02 -025 O Qu SR FORM ( Golden Rod ) 03/22 /23 6 ""