Laserfiche WebLink
s <br /> :N � =1 <br /> SERVICE;REQUEST <br /> FACILITY ID# SERVICE RE(UEST <br /> Type of Business or Property <br /> 1 BILLING PARTY i. <br /> Q%YNER 1 OPERATOR G <br /> FACSLn NAME <br /> Smm�i <br /> SITE ADDRESS `� iz Stn�tMsm� Tips <br /> ptracoon � <br /> Maiiing Address (It Different tram Site Address) <br /> �t S7AyjEry zip �C <br /> Cm ,-bC.ft-mtD LAND USE APPUCATION <br /> err. APN# I5 [ <br /> PHONE'�1 � <br /> lZl '"D3o- <br /> "' r} q" �� BOS IJtSTFi1CT LOCATI6H CODE <br /> PHONE#2 <br /> CONTRACTOR T SERVICE REQUESTOR <br /> i1r` BILLING PARTY❑ <br /> REcv;F,STOR <br /> Dr�G]7EL 7 f�S PHONE 9 <br /> BUSINESS NAME r l j�_ {z.t _.. __ Q'43_ <br /> MAiUHG ADDRESS 1"7Z' C>zl ! <br /> gD45 �= IJP /� <br /> STATE q5Z <br /> Cm ��� <br /> BILLING ACKNOWLEDGEMENT: 1. Ina undersigned property or business owner,operator or authoraed agent of same, acknowledge Thai ail sile andlor project specific <br /> PUBLIC HEALTH SERVICcs Euv ONMENTAL HEALTH DIv19roN hourly cnarges assocated with this pcplect or activity wN be billed to me or my business as identified on this farm. <br /> I also cerby that I have prepared this application and that the Work to be performed wil be done in aaardance with aU SAN JOAOUrN COUNTY Ordinance Codes.Standards,STATE and <br /> F_DERALlaWS. <br /> -- <br /> ApPLSCANT SIGNATURE: +H <br /> OTNFrZ aUT}tORIZEo AGENT ❑ ENCS 1n5� <br /> PAOPERrrlBUSINESSOwNER ❑ OPERATOR196RAGER A Tine <br /> sAavuGwris nd tf'e d!1 Ja P+ATY.proof of authoruarlon to sign is rv"ind <br /> AUTHORIZ 4TIQN TO RELEASE INFQRFdAT14N:When applicable.L the owner or operator of the property located at the above site address.hereby aulhodxe the release of <br /> PUBUG HEALfH <br /> any and all results,geotechnical data andlor envlresmentaVsite assessment into matron to Use Sur JOAQUIN COUNYY SERVICES ENvIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE Of SERVICE REQUESTED: <br /> F� <br /> COMMEFtTS: <br /> �D r4(Ae -la �(� oylg- VA [e-Mey- .57eW PAYMENT <br /> 8' RECEIVED <br /> JUL 2 6 2000 <br /> SAN COUNTY <br /> PUBLIC fJEOALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR 5 SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �( A t)� EMPLOYEE�: DATE: <br /> ASSIGNED TO: J EMPLOYEE R: �r j� DATE: <br /> r E: 6 3 <br /> Dake Service Completed (If already completed}: SEizvtcE CGDE: <br /> 3 l <br /> Fee amount: I Amount Paid Payment Date -7 aG/p0 <br /> Check Received By: <br /> Payment Type Invoice ��71 f <br />