Laserfiche WebLink
Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# SE$VICE REQUE T# <br /> rL(U�o j <br /> OWNER I OPERATOR <br /> 131LUNG PARTY 0 <br /> FACILITY NAME <br /> SITEADDRESS �� \ <br /> Street Nwnbr Wec6on �- '�tr�t N r TY� ' <br /> Mailing Address (If Different from Site Address) smt•� <br /> CITYj� q <br /> ✓- - LA " V'N� STATE r zip <br /> PHONE#1 C <br /> �T APN# LAND USE APPLICJITIONf <br /> PHONE#2 <br /> EXT' BOS DISTRICT LOCATaN CODE:. rj'. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BUMG PARrr <br /> u-1-G <br /> BUSINE NAME <br /> PHONE# per, <br /> MAILING ADDRESS ( o c7 <br /> FAX# <br /> CITY �l '( <br /> STATE zip <br /> BILLING ACKNOWLEDGEMEN : I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andror project specific <br /> PUBLIC HEALTIi SERVICES ENVIRONMENTAL HEALTH DwioN hourly charges associated with this project or activity will be billed to me or my business as identified on Gels form. <br /> I also certify that I have preparedp' tion and that Ut <br /> FEDERAL laws. to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> APPLICANT SIGNATURE: �^ <br /> J' DATE: <br /> PROPERTY/BUSINESS OWNS O OPERATOR/MANAGER t✓ OTIIERAUTIIGRIZEDAGENT Q_ Ao <br /> -� _ <br /> IlAvvcr,.wr is riot the w nrtrY prvol olauthcrizaUon to sign is raquirod itle <br /> TUo <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,Ute owner or operator of Uie property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaUsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES EPN RONMENiAL 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: t <br /> Lo lel <br /> COMMENTS: <br /> PAY <br /> RECEIVED <br /> AUG 2 8 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTOR'�SIGNATIJR[: <br /> APPROVED DY:, <br /> EMPLOYEE#: <br /> �xDATE: <br /> ASSIGNED TO: c /� EMPLOYEE#: (�1� DATE: <br /> Date Service Completed (if alre dy completed).- C <br /> SERVICE CODE: .P!E: <br /> Fee Amount: �'2 (0 <br /> zj S Amount Paid .45 , Payment Date <br /> Payment T pe Invoice#' Check# <br /> :77)b�,1 Received By: <br />