Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> A-h-b rvt- P m ID/19Gl 21-(5 O <br /> OWNER I OPERATOR BILLING PARTY 1J I <br /> p-C-C) C-V I <br /> FACILN E <br /> SITE ADDRESS I V 1 <br /> Ca n ` I <br /> StrtelNumer Dinctlon ( r SinnXim� Type Sulu! <br /> Mailing Address (If Different from Site Address, <br /> CITY STAT, ZIP <br /> 5)t-G I C <br /> PHONE#'1 - APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> �1� �a 2, <br /> BUSINESS NAME PHONE# *• <br /> MAItJNGADORESSF <br /> O '3 � r s e d yl-) <br /> CRY UA✓LC�W (' \ , 1 STATE �^ n ZIP(r <br /> BILLING ACKHOWLEDGE ME_f[T• I.",e unde^fined prouerty or business own-m oo"for or authorized agent of same. adcnowted7e that III site and/or omied se°GGr. <br /> BveLr"FAL114 SERVICES ErrnP. -IvA1 HEILTH Crrr;ral hmdy diarges as:4=1.ed wMi tits prol'r:7 a'irtT wA be NW b me or mT bvskmS es d�`d3--n `7-T" <br /> 1 also rprfify that I have prepay i5 nand that the work to be perfomred will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Slandards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT lrrV-Ri r 1 fn"?er <br /> h Ar Lr-wr Is rd Bb Oi i pau <br /> M PAR Proof of fhodration to sign is re" <br /> 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 <br /> any and all results,geotechnical data andler environmentaVSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same timet is Dmvided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �/C-C��� a�4 <br /> / 11 5-h <br /> COMMENTS: / C-!, <br /> PAYMENT <br /> RECEIVED <br /> FEB 2 5 1999 <br /> 130.1 JOAQUIN COUNTY <br /> PUBLIC HEALTH SURVICES <br /> ENVIRONMENTAL HEALTH DIVISInN <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: r EMPLOYEE#: O `c DATE: ;z- �5 <br /> ASSIGNED TO: W t EMPLOYEE#: 01 O 3 DATE: }S �( <br /> Date Service Completed (If already completed): SERVICE CODE: D 3 4I P 1 E: <br /> o J <br /> cee Amount: eia- Amount Paid 3 Payment Date <br /> Payment Type V/ Invoice# 054 yq t Chenck�0 Ia y Received By: ( . <br />