Laserfiche WebLink
SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATQR <br /> v` ` BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS II (( II � U.I. <br /> �/I <br /> RretFNumler `Qir .I. � treet Name Lrp�e� Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY X STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR t <br /> BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> o q q 3 L 3 7,S- <br /> MAILING ADDRESS � � nFAX# <br /> - 0237 <br /> CITY lz'C,C STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed t0 <br /> me or my business as identified on this form. <br /> I also certify that I have prepared t application and that t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standa:=ws' <br /> APPLICANT SIGNATURE: DATE: l Y � <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ / <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sigh is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (�b'I mo� (j i I l <br /> tl <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ THER ❑ <br /> PAYM 3W. }'l <br /> DEC <br /> ---...---------._.__.--- -- -..-- SAN JOAUUIN COUNTY - —— <br /> PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS!ON _ <br /> INSPECTOR'S SIGNATURE: j CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: O)o l DATE: j� --2_-3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 4'" Z P/E: L4 21-0 <br /> Fee Amount: —D Amount Paid $ 56:�' C) Payment Date /a 3�G <br /> Payment Type u/ Invoice# Check# �,,Z Received By: <br /> r11A ��- �"• <br /> Y- I,, " 1�� <br />