Laserfiche WebLink
1-0/20/2000 11:35 2094683 FIFTH FLOOR • PAGE <br />Type of Business or Property <br />SERVICE REQUEST <br />FACILFTY ID 4 <br />OWNER I OPERATOR <br />FACtury NAME Q(j f Tv)o e e, --s :o 13 <br />SRE ADDRESS <br />C!z7don C_ D t:.. ✓� <br />(7 L <br />Strret Name <br />Mailing Address (It Different from Site Address) <br />Crrr <br />Lac <br />PRONE :1 exr. <br />PHONE N2 <br />M <br />SERVICE REQU <br />IE <br />APN M LAND USE APPLCArcN Yr <br />E08 DISTRICT LcCAT,oNCOOE': <br />CONTRACTORI SERVICE REQUESTOR <br />PAiM Q <br />Swu S <br />Rl=QUESTOR _ <br />P, D . Y c EL E5 BILLING PARTY ❑ <br />BUSINESS NAME_ - �I2PHONES 7c,2 <br />Fr 1/}rf6C.C� CTIV ik'L//f1��17�}C )l�� S�5 ��� /UzCD <br />1tiiAlUNG AnapFss, F,ix <br />zszs iv . a�ck.P�an �v� cry pyo -6-7 <br />Cn 13L(P,6,1)1\) STATE ell ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undet�i ned property or business owner, operator or authortred agent of same, ach a+Aedge 'Wt all site andlcr project syec=frc <br />PUgUC HEALT14 SERVICES Ew-,FteNMENTAL HEALTH Oms;oti houAy charges aswaated with Gtis projector activity uAv he tined to me cr my business as idert:Fed on this form. <br />I aso certify that I have prepared this appfiC2jon and that the wart tp be perft aped ,.0 be done in accordance with all SAN JCAOUw CCUrrrY 0rd5,,ence Cedes. SWio` Yds, STAY-= and <br />FeoEPAI_ laws. <br />APPLIC.Axr Sic;wuRE: ✓ ' ZL _ LLL I - - DATE _ �/Z <br />PROPER Y I BUSINESS C'NNER Cl OFERATOR/ h,VM F_R ❑ OrniEQ AUTR4n9JT':0 AGFM ❑ (,( r� t G� c C� <br />KAAa_rwrr.notthey rgPARre.p*fofjuumriatfonrvj nismqu,;d TWO <br />AUTHORIZATION PO RELEASE INFORMATION: When applicable, L the owner or operator of the property ;ocetedd at the above Site address. hemby authorize the release od <br />any and ati results, gaotedmicsl dan and/or ervironmentaVsitq assessment infortratfon to the SIM JOACUIN COuxrY PU8uc HErLTH SEiv�-3 ENvrRcn% --ffAL HPALTI CrvurN as soon <br />as d is avat!able and at the same time it is provided to me or" reprnrertCttive, <br />TYPE OF SERVICE REQUESTED: <br />, <br />COMMENTS: <br />R E C E I V F- C <br />NOV 1 3 2000 <br />SAN JOAC)UIN COUNf'r <br />PUFIFIC NFAITIi I r;VICI S <br />FNVIRONNIFNInl HFPLTHIIItiI;I Ii, <br />INSPECTOR'S S <br />- CONTRACTOR'S SiGNATurm <br />APPROH/ED BY: <br />F-uPL.OY-- ` <br />� C ,.S— <br />CATV <br />ASSIGNED TO: <br />EvPLOYEEfr'. <br />C <br />DATE. <br />Date Service comp[Ah al tornpleted): <br />SERVK--CODE •- . t' <br />P! E:. . <br />Fee Amount <br />Amount Paid ? <br />Payment Date <br />,�, <br />Payment TypeInvoice <br />Check <br />7 S ,S <br />L <br />Received By: % L <br />