Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 14-U c IZ44— gQ <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> /M Fz • �N SKr P PP/A NV <br /> FACILITY NAME <br /> Ee6ftAA1Q RANO Pf4c 41f4 EP <br /> SITE ADDRESS <br /> k StrettNumbv I. wkctlon /St"Hame Type subs <br /> Mailing Address (if Different from Site Address) <br /> P. O . agpx 03 <br /> I Ctrr O s_ STATE Z!P � O <br /> PHONE#7 � UT. APN# LAND P <br /> ( i o J� 6940-1-5 '_b <br /> PHONE#2 BOS:DISTRu r LoCATtotV CooE . <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTORBILLING PARTY <br /> DO <br /> BUSINESS NAMEPHONE# Err. <br /> MAILING ADDRESS �. �X � FAX# <br /> CITY / n STATE CA zIP� 3 S <br /> C/l fC <br /> I BILLING ACKNOWLEDGEMENT: I,the undersigned 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 howdy charges associated with this project or activity will be billed to me or my business as identified on this farm. <br /> also certify that I have prepared this p bon and That rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: t7 <br /> PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGFR OTHER AUTHORIZED AGENT fly <br /> YAPPUcmris rat proatef aulhorieadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results.geolechnical data and/or environmental/site assessment information to the SAN JOAQutN COUNTY PUBLIC HEALTH SERvrCEs EmnRoNMENTAL HEALTH DN ION 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 /> / A d/4d/IC/ <br /> !� <br /> COMMENTS: 2� /-)— D G 11j <br /> PAYM E N`l%-� <br /> r2e"4"fit, ., - RECEIVED <br /> DEC 12 2001 <br /> SAN JOAQUIN COUNTI <br /> p cnf PUSUC HEALTH SERKFS <br /> !Q - 'Ef,JlROhlt"FNi4i lFAfTLIf?IVISf(;, <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:, f EMPLOYEE#f: e�7 Y/ DATE: <br /> ASSIGNED T0: EMPLOYEE#: DATE: f A Ld <br /> Dale Service Completed If already completed): SERVICECODE: vim' P 1 E: <br /> Fee Amount: ==Amount PaidL� Payment Date <br /> LP:a:�ym=entType T invoice# Check A 1-3 4 Received By. <br />