Laserfiche WebLink
SERVICE REQUEST <br /> Type,of Busoess or Property FACILITY ID# SERVICE REQUEST# <br /> RI✓-rNI L C,A 5•o It-LF A000 �j'�f� 8D�'S <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> Q U 1,tC S't'019 W1 A-R. IL F T S <br /> FACILITY NAME / 'Z I <br /> GL 0 1 IL -r0 P <br /> $READDRESS W G to V I S E <br /> I I i 6 Sa.n N...r J­­01rectim, A v E. <br /> Stmt Nxn. TYP. SuR. <br /> Mailing Address (If Different from Site Address) <br /> S L —+ E r,L'r�, <br /> Crrr STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (rro) (p S} - 8 S-o O <br /> PHONE#2 BOS:DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> IM ( CIA I'I✓L WA Uro <br /> BUSINESS NAME PHONE# Er. <br /> p, (. TOn( ��c<, Ir�EL12r�C< �K C - rb 3-4 frSZ <br /> MAILING ADDRESS FAX# <br /> �. 0 • •B (9w <br /> Crnr S STATE C A ZIP C S 6 Ct I 2. A VIA t:►�-o v <br /> BILLING ACKNOWLEDGEMENT: I, the undersgned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMsioN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application d that the work to be perfo will be done in aoconiance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. .�� <br /> APPLICANT SIGNATURE: DATE: I ZAl— Cr O <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C arm �T O <br /> If Avaiawr is not rhe BtLr c PNrrr proof of authoriz2Uon to sign is rvputrvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> ,DEC 3 0 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH EPARTMENT <br /> INSPECTORS SIGNATURE: <br /> CONTRACTORS SIGNATURE: <br /> APPROVED BY:. !_t VF (,eA EMPLOY E#: O _� DATE: 3 G cs . <br /> ASSIGNEDTO: V0&J Ft Ct EMPLOYEE 9: F3 I—] DATE: 1Z�3C) <br /> Date Service Completed (if already completed): SERVICECODE: C� ( P I E: ;2 ,ug <br /> Fee Amount: ZZ�, c�u Amount Paid Payment Date ( 3D <br /> Payment Type Invoice#' Check# i D Received By: <br />