Laserfiche WebLink
z <br />SERVICE REQUEST <br />Type of Business or Property <br />BILLING PARTY <br />FACILITY ID # <br />SERVICE REQUEST # <br />1� 1 L c_ S tFA• <br />MAILING ADDRESS `C `���^� <br />2 <br />OD 4� 1/B S" <br />5�2 d 3 33 9 Z <br />OWNER IOPERATOR <br />STATE GA 71P 6j S2Lk 2 <br />BILLING PARTY L] <br />FACILITY NAME F +—t",<i-, G tl-cl <br />C Pvvy P—O <br />SREA�D(ORESS <br />CP +21 Strut Number <br />Oir .. <br />St zet Nme <br />Type <br />Suiari <br />Mailing Address (If Different from Site Add.ress) <br />E V1R� <br />INSPECTOR' E: <br />CITY I _ <br />STATE <br />CA ZIP p�2q 2 <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />U� S <br />. �.A <br />,q) GN� TO: <br />PHONE #Z �T <br />BOS DISTRICT .:; <br />Date' Servi a Compl a <br />LOCATION C_ OOE: <br />cc <br />P I E:.Z3 0 �'- <br />Fee Amount: [� �! <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />�����,1� CJ+•� I NC�Sf� <br />BILLING PARTY <br />BUSINESS NAME <br />COMMENTS: <br />PHONE# �r <br />� <br />MAILING ADDRESS `C `���^� <br />2 <br />F1 3 l <br />CITY t ,, <br />STATE GA 71P 6j S2Lk 2 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />Pusuc HEALTH SERvicEs EwRONMENTAL HEALTH OwioN 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 and that the work m be performed will be done in accordance wish all SAN JOAQUIN CcuNTY Ordinance Codes, Standards, STATE and <br />FEOERAL laws. <br />APPLICANT <br />7 <br />DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MLNAGE`R 9/ OTHER AUTHORIZED AGENT ❑ <br />MAPPf.GWr iz not the Bx•mG Purer proof of audi r¢atlon to sign is rsquirad 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 envimnmentallsite assessment information to the SAN JOAQUIN COUNTY Pusuc HEALTH SERVICES ENVIRONmeffAL HEALTH DIVISION as soon <br />as it is available and at the same lime it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />APR _ � 2pp3 <br />N JOPD `.�� Egg CE <br />S P oN\S`�N <br />`�G HEA NEp,�TN <br />MSN�P` <br />E V1R� <br />INSPECTOR' E: <br />CONTRACTOR'S SIGNATURE: <br />,4PROVED B <br />ElIPLOY�i: <br />kDATE— <br />. �.A <br />,q) GN� TO: <br />EMPLOYEE#' 3B <br />Date' Servi a Compl a <br />SE2VICE000E: <br />P I E:.Z3 0 �'- <br />Fee Amount: [� �! <br />Amount Paid [ f <br />Payment Date p 3 <br />Payme Tt Type <br />Invoice # <br />Check # 3 ( <br />Received By: 26� <br />