Laserfiche WebLink
—'W <br /> SERVICE REQUEST <br /> Ty f Bu in ss or Property FACILITY ID# SERVICE REQUEST# <br /> 6 S <br /> 0 NE PERATOR 1 i BILLING PARTY i. <br /> FACILITY AM <br /> i SITE ADDRESS /y/� 66&2i2 <br /> Street Number Direction / / Street Name Type Suke# <br /> Mailing Address (If Different from Site Address/') � <br /> •C,CJ �_ <br /> CITY j ry;`� Lam/, lSTATE ZIP <br /> L 41-1 C06 3P ONE#1 APN# LAND USE APPLICATION# <br /> 0 L77,)I-69�:;Z <br /> PHONE#2 fir• BCIS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO n •-� BILLING PARTY <br /> ( AAALL 11-T <br /> BUSINESS NAME ' P NE# ���/C �3 _��T• <br /> MAILING AD RESSF <br /> 2Z �- <br /> CITY r � STATE ZIP <br /> BILLING ACKNOWLEDGE✓MENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andV/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 form. <br /> I also certify that I have prepay this appMication and that the to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER Qli OTHER AUTHORIZED AGENT <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH 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 /> ( - <br /> COMMENTS: <br /> PAI M `erl`e <br /> nEC YEV^ <br /> JAN 18 2000 <br /> SAN JOAQUIN COUN TY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH D!V*40N <br /> INSPECTOR'S SIGNATURE: r CONTRACTOR'S SIGNATURE: <br /> APPROVED DI. /� , �1 EMPLOYEE#: (J <br /> A L3 <br /> DATE: rV <br /> ASSIGNED TO: h (• EMPLOYEE#: , - �� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �'. PIE: <br /> Fee Amount: �_ Amount Paid Payment Date ` -L D <br /> Payment Type Invoice# Check# Received By: <br />