Laserfiche WebLink
- - SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVI ST# <br /> F 16CoAgyuq# ovn YYleter�al5 <br /> OWNER 1 OPERATOR BILLING <br /> 102!t4-rile rL <br /> FACILITY NAME <br /> SITE ADDRESS W HwK l� <br /> St(A SrWNe v Detion U strw N., Type Suits/ <br /> Mailing Address (If Different from Site Address) �r p!� y' �1 <br /> CITY Lod e STATE C ZIP —1 7 014;41 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (OW 334- 4o3g 05S-l60- 4 f5 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTORBILLING PARTY❑ <br /> ilei l O. I4vt4evsov, d- rjS50c.- -1l rill- <br /> BUSINESS NAME PHONE# ETT. <br /> bovwe., cis eboue on 3(67 -3701 <br /> MAILING ADDRESS FAX# ( (� <br /> 01,01N HOA40yn b, <br /> CITY / ._ 1; STATE /I,d LP J a')0, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepared this application and that the work to be pedonned will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL lam. <br /> XAPPLICANT SIGNATURE: _ V DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPRKhvr is nor rhe EAu+c Pum:proof Ofaurhorkarion to sign Is requvod Tiffe <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaysite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same tme it is provided to me or my representative. <br /> TYPEOFSERVICEREOUESTED: <br /> COMMENTS: c l —'.yt/I ''��..�,, JJ Ip wVVa,■r \� <br /> -/-6/66 I eViewEc� �D.� OLtii�al�Otlr /N'f iota l�Clr yp, rMEtN,ENl'. <br /> eyixw s 4v -Zoyiortl o,- loorC�L- ;t-Id, o iA- ,r r`vy�/,'rRECEIVED <br /> MA+,+nk yw �}'�..- Ct..�l,. ��nrSC./�",/.. � bc.hu-fts W01620 <br /> (vJ SAN JJAUUIN COUNTY <br /> pUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: 9)e6'( t DATE: 3 -/ <br /> ASSIGNEDTOt Q;-,,h •^.L /I EMPLOYEE#: -3 DATE: 9-/[e--.v[J <br /> Date Service Completed (if already completed): SERVICE CODE:SC' *j 2 5 PIE: oZ(o. O <br /> Fee Amount: 3q Amount Paid 3RD Payment Date i <br /> PaymentTypeeK Invoice# Check# Received By: <br />