Laserfiche WebLink
07/.11/2005 13: 28 91E9277 4 CHAMPION PT INC• PAGE 91 <br /> s sAN ioAwri CouNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typo of Business or Fmpsrty FACILM ID* EST tt <br /> C-Ir <br /> • ,yDr� �5�`rt <br /> OWXM 1 QPWL%TORClaiGr Ir l 1 O <br /> iv <br /> FAcasNABe f1 �• <br /> Sll•E AoClieas <br /> ear �ilr_. z <br /> iVtvI1B or VAL=AStnraEss ie Ctteanant iron ats,Addrsas) <br /> Cmr STATS 21P <br /> PMosstll �• ArN i t a►o UK A"n"TiON! <br /> { 1 <br /> PHOItE tR 00"W'r i ntwe►110N CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> ftaueffm <br /> rHDA n <br /> ausa,sssNA1P v ►� 1 �` <br /> t IoNE orMiuurlG ADDRi93 FAxi< <br /> terSr %jDjC� MP <br /> clot 29-63LA <br /> B1I.11NG A MENTI. the undersigoW Property or irasisresSs osraer,operator or nothorb Wd of acme, <br /> acknowledge that all site and/or prgeet specific ENVM0WMXN7-ru.R%ALTH.OFPARTMENT hourly charges auwigtd With this project <br /> a'activity will be billed to erne or my busiaeas as idolltified on.this form <br /> I also certify that I have prepared this applicatim d tt+at the work to be performed*0 be dome m accordow w>tb all Sir IoAQvtN <br /> Cows,Ordbxmm Codes,Sltmtdmb,STA-0 <br /> APPLICANT'S SIGNATUSM: <br /> rAQTL�TY/BUS070%t.h"AmCl �;= <br /> IfAi'PLFCAM IS+rat the(�1/ q Ptfmriz on m riga tPa tlLfEd Ttrft <br /> g�•ORIZA ON:When applicable,1,the owner or operator of the property located at the <br /> abeft site address, hereby ao8wrize dw release Of any and C results, geotecbmiral data and/or envs lsrte awss"Im <br /> infot motion to the SAN JOt%QllTN CMM'y EWSR(A7MrJ4TAC l•(F.AI.TN Dr•,rARTMENl•ag Own as it is I 1 time it is <br /> provided to me or my mrresenstive. <br /> Tire or SWWE RfEMMWW-' U_ST P�`' c F r 7" <br /> �,,.Etr�: J . <br /> � SANJOAOu1N COTALTM <br /> EN\JIREO -NEW <br /> HEpLTN DPAR <br /> ACC6"W Br. 0L EMPLOYM* Z-( DAME —7 <br /> AMCMD TO: LX%l�� VKDYM C:3 DAM. 'Z l S�S� <br /> own Servk a Completed (ff atraadp=swk*W): t;OOE ( P l ..3. G <br /> Fee Amount �Z 9•cYv Aatouet Paida,'1 q. D c7 f aytment Owto '1 1 y D S <br /> Payment Type Invoira 9 Check tF "y PeWved ey: <br /> EHD 48.02-025 Sia FORM(GoidW Red) <br /> RE\ASED t ViTI 003 <br />