Laserfiche WebLink
SERVICE REQUEST <br /> i Type of B 01ness or Property \ FACILITY ID# SERVICE REQUEST# Olk3�",( <br /> OWNER/OPERATOR BILLING PARTY 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> SbioNumbw Okocbm ` Name Type suite <br /> Mailing Address (if Different fro Site Address) <br /> e C Gk, Cs-� CA c 3� <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION COQ <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PART�4 <br /> BUSINESS NAME PHONE# EXT. <br /> Itks-a33 <br /> MAILING ADDRESS FAX# <br /> CITY �L1 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,admowtedge that ad site andlorr Project specific <br /> PuBuc HEALTH SERvICEs ENVI ON AL HEALTH DIVISION hourly charges associated with this project or activity wil be billed to me or my business as identified on this torn. <br /> I also certify that I have prep is ap ica' be performed vA be done in accordance with all SAN JoAwN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALLM. <br /> APPucA nr SIGNATuRE: DATE: C <br /> PROPERTY/BUSINESS OYVN OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT <br /> IAPPUCv ot <br /> iSnftSLL cPwrvproorpnfofmdwrfsadontosismr <br /> 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 relesse of <br /> any and all results,geotechnical data anWor emironmentallsite assessment information to the SAN JOAauw COUNTY PUBLIC HEALTH SERVICES EwRoNNBITAL 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: �i_ �! A-51 <br /> COMMENTS: <br /> �e 6/F <br /> FEB 19 1999 <br /> Lif :ice rrVtCS <br /> VIAL ffEgLi'H GIV1g,y <br /> INSPECTOR'S SIGNATURE: R'S STUR <br /> APPROVED BY: ESIPt QYF�A:� , <br /> ASSIGNED To: I n �, �� EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE COW -P I E:.� <br /> Fee Amount : 0 Amount Paid ��3� Payment Date a r I l et <br /> Payment Type � Invoice# Check# Received BY (i{�°j <br />