COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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' SERVICE REQUEST , 1 - --- % -- Type of Business or Property dO , CL,o-> .S-1- et-C-1-a'-N _ FACILITY ID # 1;54 coo3563 SERVICg RgQVEST,tt TH So20 , i i OWNER! OPERATOR BILLJNG PARTY DI LA__ CST_ L.-- / FACIUTY NAME ....7 SE ADDRESS ?'194 Street Number e-- r-rz Otreeuen 1 Street Name Type Subs $ Mailing Address (If Different from Site Address) Co-( STATE ZIP PHONE. #1 Ecr. iA ) 4/- S?93 APN # LAND USE APPUCATION # PHONE #2 Fxr• ( ) BOS Dis-rnci LOCATION CODE CONTRACTOR! SERVICE REQUESTOR REOUESTOR 9t17 -0,Y514,--- BILLING PARTY e....' ut Aqr- 173 BUSINESS NAME --)1---; tt_\-irce: _-\- CI. Ps TTCYN S YCTE.- 11\C , 7 ,11( • PHONE # 9 - 7)1.3 EXT. MAIUNG ADDRESS FAx # cm,STATE ce ZiP c--) BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project speadc Pusuc FiEALTN SERvrcES ENviRCNNENTAL HEALTH DMSION hourly charges associated with this project or activity will be bdled to me or my business as identified on this form. I also certify that have prepared this application and that the wort to be performed will be done in a=rdance with all SAN JOA011iN CouNri, Ordinance Codes, Standards, STATE and FEDERAL laws. APPUCANT SIGNATURE: in L.11)...1' PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 CrrliER AtfrHORIZED AGENT Er-- ff APPucur is not the 0 [LNG Fume proof at autaottotion to 31V is iiiiiiiired Titl e 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 any and ad results. geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN CouNTY PuBuc HEALTH SERvicEs ENvictomENTAL HEALTH OmsioN as soon as it ls available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Comm: oatt j Peie-:.a—) -te PAYMENT 4 RECEIVED rK.1 JUL 9 2003 ,4-791 frt2d /4t/z 1)s/ .-#1.-7,--1/4A .5.A l'it, iSat4Aii"" 194 l •‘ , , iteett..14,4-(2 Aeme,„, tj it-A" SAN JOAQUIN COUNTY 7/ it 15 PUBLIC HEALTH SERVICES : 0-)--e-1 /2./f -- d-4:1 #" ENVIRONMENTAL HEALTH DIVISION CONTRACTOR'S SIGNATURE: - / Info 11.4 <114"(1114"1 rk frtee4 rt 1-4.g-talc" INSPECTOR'S SIGNATU E: APPROVED SY: • , _ ___FaPLOYEEt, >-;, / 67. DATE: 7 ASSIGNED TO: )'2 4 ( , ,t,., j _ EMPLOYEE It: 51-0 DATE: Date Service Completed (If already completed): SERVICE CODE /13 IE:.-Th --., ---f--- 0 err- Fee Amount c2.4 -7 I Amount Paid 02 /, 7 — 1 Payment Date 7 61. I c 3 Payment Type 1.,/. Invoice # Check # i 99 L743-77 Received By: ____. DATE. /en3