COMPLIANCE INFO_1996-1999 - Laserfiche WebLink

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SERVICE REQUEST Type df Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR BILLING PARTY FAcom NAME SITE ADDRESS ��lo� svu 9umb.r otowbon � � sn..r►uw. rya. sone x Mailing Address (if Different from Site Address Clrr ESTATE ZIP `SIA (• ,P PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE#2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR I SERVICE REQUESTOR REQUESTOR BILLING PARTY❑ BUSINESS NAME PHONE# g Exi MAiLINGADDRESS1 FAX _ CITY (J . STATE (_C,_ LP BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,opeator or authorized agent of same,acknowledge that all site and/or project specific PUBLIC HEAL NTAL HEALTH 0 a es associated with Bus proiectoractivity will be billed to me or my business as identified on this tone. I also certify,that I have p application and that the work to be perfiprma be done lo accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT SIGNATURE. T DATE: `l t k y PROPERTY!BUSINESS Cl OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑t p i L-A- - ffAwucmrsnorrhe8cuvcaNrrvproofota�,nrorrunarMsignis —r rifle 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 any and all results,geotechnical data arnilor environmentalfsite assessment information to the SAM JoAOUW COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH OnnsloN as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: �ti\ DEC 17 1998 SAN JOAQUIN t. ENV PUSUC HEALTH MCE INSPECTOR'S SIG MENTAL SERVICES CONTRACTOR'S SIG APPROVED BY: rj L EMPl.0Y--#: Irle - DATE: ASSIGNED To: /� EMPLOYEE#: O C DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount Amount Paid Payment Date Payment Type Invoice# Check# Received By: