Laserfiche WebLink
v <br /> SERVICE REQUEST .1 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# C <br /> T <i Co U 1 —] - <br /> OWNER I OPERATOR LUNG PARTY Q <br /> FACa.fTY NAME /I <br /> SITE ADDRESS Ito <br /> Mailing Address (If Different from Site Address) <br /> CITY / STATE-& ZIP <br /> PHONE#1 J I` �T APV# LAND USE APPLICATION If <br /> PHONE#2 SOS DISTRICT LGcAnoM CODE - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> LOU <br /> B1151NE55 NAME 1 )r1 ( NE# _;�?j-,q—,34- exT• <br /> MAILING ADDRESS �bq L'- Fes# <br /> I Lim <br /> CITY STATE ZlP d✓Y <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowiedge that ad site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION howdy duges associated with tics project or a[9vily Will be Lo)))ad to me or my business as identified on this fans. <br /> I also certify that I have prepared this pl' tan and that th parforme be done acmNance with ad SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �y <br /> APPLICANT SIGNATURE:�'.f �E/� v DATE: <br /> PROPERTY]BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> UAwLr iSnG(VXSELMPWnr.Mod ufautlrodaeon M&ran is repudnd Title <br /> 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 <br /> any and all results,geotechnical data an Uor envkonmentaltsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as t is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3 / MEET <br /> DEC 7 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMS!('' <br /> INSPECTOR'S SIGMA RE: CONTRACroR$SIGNATURE: <br /> APPROVED BY: ",` EMPLOY. : � L <br /> --& (_D l DATE: l <br /> ASSIGNEDTO: ,!-� EMPLOYEE#: C' CjO <1 DATE: (Z L <br /> Date Service Completed (ff al6h completed): Si DIE <br /> 'PI I- <br /> Fee Amount " Amount Paid Payment Date <br /> R BY'• <br /> Payment Type Invoice# Check# <br />