Laserfiche WebLink
05/06/2002 09:52 4640138 ENVIRONMENTAL HEALTH PAGE 08 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVMFttlIm BtILrNG PArzry is <br /> FACttm NAME , <br /> SITE ADDRESS <br /> StreetN�bK eke�?ort , SQeHNticae Trne Safle! <br /> Mailing Address (IF Different from Site Addressl <br /> Cn y S°TAT6 ZIP <br /> PHONE#4 APN# NAND USE APPLICAlmm# <br /> PHONE 92 Ext• <br /> LEOPISTRICT.Z.. <br /> J�`M.I. •1a - i1 :']��,4R„�1';i.•.•�v:b'' .. 'P• <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BSG PARTY 0 <br /> BUSKM NAME • PHONE# Fxr. <br /> ® (-Q(±1239 0 103 <br /> FAILING ADDRESS • FAX# <br /> 4 t sCzy <br /> s <br /> k,• SAYE ZtP `t� <br /> BILLANG ACKNOWLEDGEMENT;t,the undersigned properly or business owner,operator or authar;Zed rent of same,awe that all site andlar pmject spedr�c <br /> PUMC HMTH SERVICES ENmONMENTAt HEALTH Dru nN hourly charges asslated with this prood'or artivily wM be Bulled to me or my business as identtied on SES harm. <br /> I also oar*that I have prepared this application and that the wort to be pedomaed will be done in aooanlance with all SAN JoAam County Ordinance Codas,Slandard;,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DAA: 1P b <br /> PROPERTYIBUSINESS OWNER 0 OPC•FATaRIMANAGER 0 OTHERAt1YNEORIZEDAGEM )a <br /> RAPptrCaxtrY la0t fi�t�+c Pvnr prvororwthorftatloe to s�pn Ls�sQuFrod rifts <br /> At THORt7ATION TO RELEASE INFORMATION:When approble,I,the owner or operalorof the propotty touted at the above site address,hemby authorize the release of <br /> any and all results,geotw hnic al data andlar enuironmentallslta assessment Information to the SAN JOAOUW COUMTr P6=HMTIE SEIM=ENMONMENTAL HEALTH DrMIM as soon <br /> as Itis available and at the same time it Is pmylded to or my representative. <br /> TYPE OF SERvice REGUME=D: <br /> COMMENTS: s"� <br /> a <br /> a <br /> INSPECTOR'S SIGNATURE' CONTRACTOR'S SIGNATURE: <br /> APPROVED oy,. EMPLOYEE#: DATE: <br /> ASSIGNkb TO: EMPtoYEE#: •DATE: <br /> bats Service Completed (if already.complct4: SEltvacECaoE: P/E:. <br /> t.. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice N• Check 0 Received By: <br />