Laserfiche WebLink
a lti/20/2'000 11:35 209468 <br />e <br />Type of Business or Property <br />OWNER / OPERATOR <br />i ACIt rrY <br />MAUI! <br />FIFTH FLOOR <br />SERVICF, REQUEU <br />FACIUN ID 4 <br />0-Wk57P PA -a .�� # 13e <br />SITE ADaRns <br />L ! nl e o L of 91- ✓.D . <br />�0'eat Number O�esa9ee shore Name <br />Mailing Address (lf Different from Site Address) <br />CITY ®. <br />PMONE #2 <br />AiA <br />PAGE 01 <br />SERVICE PEGUEST # <br />0 VI/ <br />5TA ZIP <br />La <br />AP N # LANo USE APPUCATION # <br />EOS DsSTRtC1 l gcanaN Coar <br />COffMACTORI SERVICE REOCWTOR <br />PARTY 0 <br />BILLING ACKNOWLEDGEVENT: L the undersigned property or business owner. operator or authodred agent of same. admewfedge that all she and/or project specific <br />PUgM HEALTH SEW= EnvrF 144ENTAL HEALTH OMSM tautly charges a=ciated with this project oractivity will be bred to me or my business as i wiled an this form. <br />II al that I have prepared this appkation and that the work to be performed will be done in accordance with alt SAN JCAOUW COONTY OrTmnce Codes. Standards, STATE and <br />APPLICAMr SrcuATURE: �— DAZE <br />PRCPERTY / EusMdSs CwNER ❑ OPERATOR/ WAXAM {j OT SER AuTHOPD—c i AGUNr ❑ U/" <br />Yam-cmYAIP-cmT isnot me FIM _FAnTy prwf qf audmn=rdan fo 34n & rdquka4 rtro <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L thie owner or operator of the property k=Ld at the above site address. hereby authorize the release of <br />any and ad resufts. geatechnirsl data and/or envirenmentaifsite assessment inkmt2don to the SAN JoAOUIN COuNw Puag HEALTH SEWM Sv4noNuENTAL HEk w Oms;CN as soon <br />as a is avmbbte and at the same &ne it is pruvided to me or my repmsent?d , <br />TYPE OF SERVICE REQUESM: <br />COMMEMrs: <br />RECEIVED <br />NOV 1 3 2000 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />MFECTOWS S <br />coffm rotes SIGNATURE: <br />asstcHEDro <br />F.aLOYEE#— <br />DATE <br />:'Smite Co i HaJcompleted: <br />S>atvtcECot <br />PIE. �...:.. <br />Fee Amount <br />Amount Paid Z <br />Payment Date <br />f f <br />Payment Type Invoice 9 <br />Check it <br />