Laserfiche WebLink
s <br />0 0 <br />SERVICE REQUEST EH0061SR revised 07/10/98 <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR/^ q� a BILLING PARTY ❑ <br />FACILITY NAME <br />Sc, -e S KoX Ala ✓/ e �' <br />SITE ADDRESS ;Q <br />� 0 v )6 f h� �('9 Aw a� <br />Street Nw�/err DW. "� StreN Marne Type Sub 9 <br />Mailing Address (if Different from Site Address) <br />n0- r02--2 <br />CnY '�f'' STATE /I zip <br />PHONE #1 aT• 17 I APN # LAND USE APPLICATION # <br />.' <br />PHONE #2►. BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUIESTOR <br />REQUESTOR C O / yt BILLING PARTY <br />BUSINESS NAME ✓ PHONE # <br />MAILING ADDRESS/''� ` FAX # <br />CITY CJ / o C A 7-0 '1-, STATE C+ /V- zip 17S7—os <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br />me or my business as identified on this form. <br />I also certify that I have prepared this ap Ii ti and that the work to be performed Will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standards, ST and E ERAL laws. <br />APPLICANT SIGNATURE f DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I MAMA R ❑ OTHER AUTHORIZED AGENT Ir ® <br />If APPucw is no the BH11NG PARTY proof of authodkedon to sign fs required Title <br />AUTHORIZATION T ' LEASE and <br />When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />�P <br />COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ <br />OTHER <br />❑ <br />e(,vFn <br />DEC 16 1998 <br />PUBLIC JOAQUIN COUNTY <br />ENVIRONME EALTH SERVICES <br />INSPECTOR'S SIGNATURE: ( CONTRACTOR'S SIGNATURE: <br />` t FbATE: <br />APPROVED BY: <br />EMPLOYEE #. <br />Ov V ( DATE:' <br />\ <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: P / E: <br />Fee Amount: `� (� <br />Amount Paid <br />%0,z . OU <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: , <br />