Laserfiche WebLink
e - <br /> SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of JIpsiness or Property FACILITY ID# SERVICE UST <br /> OWNER I OPERATO <br /> BILLING PARTY❑ <br /> a . <br /> ]FACILITY NAME <br /> SmADDREg <br /> v SS 0%zfzw, - / <br /> Street tiueN�er D�ctlon Strw Nutt Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY STT ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> PHONE#2 E BOS DISTRICT. LOCAmoutODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> 948 --/6 4 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,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 identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes,Stands s, ATE and FED laws. <br /> APPLICANT SIGNATURE: (�+� DATE: <br /> PROPERTY/BUSNESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑�� <br /> If APPLICANT is not the BUNG PAarc proof of authorization to sign is required Tile <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable, I, 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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERvlcEs ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is proved r my representative. <br /> 'TYPE OF SERVICE REQUESTED: cf— <br /> COMMENTS ❑ SPECIAL CONDiTION(S)0F APPROVAL❑ OTHER ❑ <br /> ,i0A0U0v L;OUNTY <br /> r P{31JG HU 1,MTH DIVISION <br /> g2 <br /> A <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> I <br /> APPROVED BY: DATE <br /> ASSIGNEDTO: j EMPLOYEE#: <br /> Date Service ompl (ff aft*completedr SERVICE Cot C? PIE: <br /> Fee Amount �3 jj�'2..�j'f Amount Pafd �3a�.o� Payment Date <br /> Payment Type oice# Check# Received By: <br />