Laserfiche WebLink
SERVICE REQUEST `- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR BILLING PARTY <br /> e XRT © AJ <br /> FACILITY NAME <br /> STTEADD ss _ <br /> �- SentNunWr o� Q Nmr Tt suft 1 <br /> ypoi Mailing Address (If Different from Site Address) <br /> Cm STATE C� ZIP <br /> PHONE#1 <br /> EM. APN# LAND USE APPLICATION# <br /> ( <br /> P4ONE#2 Exr. BOS DISTRN:r LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOuESTOR SLUNG PARTY <br /> ^�a BUSINESS NAME PHONE# <br /> i 3 B 78d <br /> MAILING ADDRESS FAX# <br /> q zo S <br /> CITY rlZc'Md T— eA / yS3 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, addtowbdge that all site andlor project Specific <br /> PUeLIO HEALTH SERVICES ENVIRONmEwTAL HEALTH DIVISION hourly charges associated with this projector activity will be filled to me or my business as identified on this form. <br /> I also certify that I have prepared this app) nd that the work to be pedomN.W willbe done in ac=daws with allSAN JOaauw COUNTY Ordinance Codes.Standards.STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: r- DATE: <br /> PROPERTY I BUSINESS OWNER H� IMANAGER ❑ OINEAAUTHORDED AGENT ❑ <br /> dAPPjcANT a not de SrueaPWrrv.prod ofaulhahi to ripe Is mwied Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.L the owner or operator of the property lasted at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data andlw wAnonmental site assessment YdOrmallon to the SAN JOAOUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OlvOM 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: �tG <br /> CAMMENrs: pAYMEN'r <br /> RECEIVED <br /> JUN 2 2 2000 <br /> PAN jOAQUIN COUNTY <br /> UBUG HEALTH S WILES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: ie CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOY--IF. DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z DATE Q <br /> Date ServiceCompleted (ff already pl CODE d 3 'PIE- <br /> Fee Amount: i Amount Paid �.4 cli,J Payment Date <br /> Payment Type "+ Invoice# Check# �. L) - Received Sr. <br /> Ym YP c)�. � � <br />