Laserfiche WebLink
11-33-1999 10:39AM FROM <br />w <br />SERVICE REQUEST <br />Type of Business or Property PAG7ury ip # <br />kOWNER 1 GvgR,s.TOR d <br />SERVICE RECIJEST R <br />Mailing Address (if Different from Slte Address) <br />P. 3 <br />BILLING PAJgTY <br />I__ rye. smu s <br />CONTRACTOR! SERVICE RECUESTOR <br />BILLING ACKNOWLEDGEMENT, 1, the undetsigred property or buvinoss owner, ooeratof ar authorteed agent r same, as lm"e hat 211 site andlor project Spocik <br />aUOLIC HE -LTH SERVICES ENvV0%CHTAL HEAL N DMS*h Avurty 0"eS a=ot aced wish this X*d or activity will be billed tC me or my business as ioenitfed on"form, <br />i also cerdify that 1 have prapared app5mtkm art,' that the wom co oe peftmed wIT be lane in amordanca with as SAN JOAUuIN CWN Y Ordinance yes. Standards, STATE Bite <br />ISDEU. laws. <br />AA <br />APPUCANT&GRA'IiRsi y~ DaTE � <br />PRI07PERTy! SUSauess OWNER OPERATOR /t <br />CNERAutmoa;LED AMM <br />Y ter theproof of W Wx30on to aloe ra ravurod tri;e <br />AUiHORZATIQN Tg REL F INFORMATION: Wren owner or operator of the property Ioc2wa at ttra atcve site aadres 9. Nereby auUwrize trre reIeasti nil <br />arY and ail msugs. geoUC w* iota andior erivUOnment- ilsits assessment Wormation to the SAN JOAotAN CCUN7Y ?UBUC J-44.rH SERVICES BwRoNN.ENTAL HEALTH DrvissON as SQGri <br />as it is available and at ttte same time R is provided to me or my Tprmr.tv#m <br />TYPE OF SERVICE REQUI!STEM <br />COMMENTS: <br />INSPEC70R'S SIONAFURE: <br />APPROVED Bu: <br />I <br />ASSIGNEO TO: <br />Date Service Completed {If already completed?: <br />Pee Amount., --%r L ] <br />Payment Type �F� j invoice p <br />EWLOYEE #-. CV0 <br />EMPLOYEE t F%f I <br />Amont paid (� 4�. 0? <br />Check 0 10 <br />SAN <br />i DATE; <br />SERF CODE:( PIEE d <br />W - <br />Payment Data <br />A c:10 { Received Sy: <br />