Laserfiche WebLink
U <br />Type of Business or Property <br />SERVICE REQUEST <br />FACILIT`( 166441 <br />----F p <br />OWNER I OPERATOR ` / C'7� L L, 1. <br />we 5 �( %c? 5 {J (tel 111 <br />FACILITY NAME n %; 0 J ' e 1 /► s� <br />f ' l.. <br />SITE ADDRESS / j o� <br />StrK n„^,e« <br />Mailing Address (If Different fTOm Site Addressl <br />STATE <br />Crry -t-v <br />r2pp"HLO�Z412 <br />r 1/`1 <br />APN tt <br />BOS DISTRICT <br />CONTRACTOR C R 1 SERVICE REQLIESTOR <br />REQUESTOR <br />SERVICE REQUEST R <br />3��� <br />BILLING PARTY L <br />LAND USE APPLICATION R <br />.yp- suit 7 <br />ZIP <br />LOCATION CODE <br />BILLING PAR <br />Ext. <br />PHONE h' <br />SL C' <br />BUSINESS NAME 'S / / //D/� I FAX # <br />f"UNG ADDRESS <br />STATE .�L ZJP <br />L� �j <br />a that all site andlor prided 5;: � �c <br />CITY ���--� C agent of same. a&nowled9 <br />I. the undersigned property or business owner, o rator or authorized <br />BILLING ACKNOWLEDGEMENT: HEALTH DrvtslOt+hounj urges assoda <br />ted with this pr°jed or adi�^tY wrV � billed m me or my business as identified on this rm. <br />Pueuc HEALTH SF Es ErmRc+++ wiUi all SAN JOA OUIN COUNTv Ordinance Codes Standards. SATE an <br />dorrned wU be done in accordance <br />I also certify that I have pfePa <br />red this appr�t�' and that the work W be Pe 2 S� — L <br />FEDERAL IaWs. DATE: Ie r <br />/j�i� Coe; <br />APPLICANT SIGNATURE: GL �% G Ory AUTryORl FD AG'r1� Title <br />OPERATOR ( ?AANAGER Rr' P ?TyTC Pr0a of autiwa2do^ to Sig, c � <br />TY 16uswE55 OWNER located at the above site address, hereby authorize the release of <br />PROPER rf APpfXJ�Nr is rxX tha <br />,ator of the property TH SERVICES ENVIRONMENTAL HEAD C)MG1ON as soon <br />AUTHORIZATION TO RELEA <br />SE INFORMATION: When applrcable, L Ute owner °r °Pe NTY PueuC HEAL <br />nical data ancUw ertvironmentaVsite assessment information to the SAN JOAOUw <br />any and all results. geolech it is provided to me or my representative, <br />as it is available and at the same time r .0 / <br />TYPE OF SERVICE REQUESTED: 4, :C r <br />pAYMEN <br />CoMMEXTS: RECEIVED <br />9 A�1 <br />INSPECTORS SIGNATURE• <br />APPROVED 13Y: �. <br />ASSIGNED TO: G /' <br />Date Service Comp <br />le'ted (if already �rnPletnd): <br />Fee Amount � <br />dtb-� <br />Invoice # <br />Payment Type <br />CONTRACTOR' SIGNATURE: d� <br />C / DATE: <br />�j DATE: Q <br />EMPLOY #: <br />SERVK:F CODE: <br />payment Date <br />Amount Paid '-P o-4 Ll <br />Check (f C 103 <br />2903 <br />COUNTY <br />2-03 <br />p <br />P I E. -_D <br />Re� <br />JAN .0 2 2003 <br />ENVIRONMtiN1 HEALTH <br />PERMIT/SIRVICES <br />