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0 Pf=nl IFST 0 EH0061SR revised 09/04/98 <br />CONTRACTOR t SERVICE REQLIESI UK <br />REQUESTOR /'C ^�'� 1 J©4 c,— • BILLING PARTY <br />BUSINESS NAM <br />% IAD /� / PHONE# <br />��C-r- _ .�14�Y ✓✓" "' <br />MAILING ADDRESS 7�7 -19w,443 ,yfT 15" /1 7�—� <br />CITY X14 SL,1 <br />Fax # <br />( 3 J s—J <br />STATE ZIP 174/ --"- <br />BILLING ACKNOWLEDGEMENT: 1, 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 to <br />me or my business as identi on this form. <br />1 also certify that I have p pared this applicatiAa/thata work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standa STA and F E <br />APPLICANT SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNER ❑ TOR/MANAGER ❑ OTHER AUrHORVFDAGENT 'r`?" t - <br />1f APPLICANT is not the BwNG PARTY proof of authorization to sign is req Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />„, C--- CA—OneMhACMTAI HFAI TH 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: <br />� t� / <br />( r <br />vv <br />COMMENTS ❑ <br />S) OF APPROVAL ❑ OTHER <br />SPECIAL CONDITIONH <br />PAYMENT <br />SEP 1 <br />SAN JOAQUIN C(0 <br />ENVIRCIVMENTAL F'�IC}=' <br />HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />DATE: <br />APPROVED BY: <br />EMPLOYEE#: <br />CL <br />DATE: O <br />ASSIGNED TO: <br />EMPLOYEE #: <br />p <br />DATE: <br />�3 PSE: ©� <br />Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount: <br />Amount Paid <br />( Payment Date f <br />Payment Type <br />Invoice " Check #ftceiVed <br />L <br />Alf) Aa <br />By: <br />I <br />