Laserfiche WebLink
SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Go 3 <br /> CWHERI OPERATOR BILLING PARTY❑ <br /> Gordon and Anne Roget <br /> FACILrTY NAME <br /> SITE ADDRESS 23020 N Sowles Road <br /> so-..r Num w olreetion si. Nma T,. S.K. <br /> Mailing Address (If Different from Site Address) , <br /> CITY Acampo STATE CA ZIP 95220 <br /> PHONE 91 APN# ANG USE APP <br /> LNina <br /> # <br /> 007-370-04 Oa - 00/0 <br /> / <br /> PHONE#2 BOS DISTRICT - - LOCATION CODE. <br /> CONTRACTOR I SERVICE REOUESTOR <br /> REQUESTOR BILLING PAM pp, <br /> Dillon & Murphy V <br /> BUSINESS NAME PHONE# <br /> 20 334-6613 <br /> NWuNG ADDRESS FAX# <br /> P.O. Box 2180 20 334-0723 <br /> CITY Lodi STATE CA ZIP 95241 <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 EwiRCNMENTAL HEALTH DNISION houdy Charges associated with this Projector activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this pri ation and that the work to be need will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: <br /> AT--t�� /,, �c_'E DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AuwR=AGENT ❑ <br /> IIAFPLGwrisnor Nsa ryPio'.Leval al wfhariation M sign&nquvad Two <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 dam and/or emironmentausite assessment information to the SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES EwIRONMENTAL HEALTH DIVSION as soon <br /> as it is available and at the same Ume it is provided to me or my representative. - <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS. 7�, !/✓ `�/'� z <br /> 3/o2�-rro� 5 Alb PAYMENT <br /> Qyr y a RECEIVED <br /> MAR 12 2002 <br /> 6 D SAN JOAOUIN COUNTY <br /> PUB`NVIRONMENTAL EAETHNDCNSSIr <br /> INSPECTORS$IGIIANRE: COMRACTOR�S SIGNATURE: <br /> APPROVED BY: EMPLCYI--#: ( DATE-- a <br /> ASSIGNEDTO. EMPLOYEE#: OCe (yc DATE: <br /> ro <br /> Date Service Completed (if already Coted): - SERVICE COO E: - PIE=- ? �pb <br /> Fee Amount t Amount Paid 8 , Payment Date <br /> Payment Type Invoice# Check# 3(„ Received By-,blzd,- <br />