Laserfiche WebLink
0 • _ SFRVICF RFrVlccr 0 <br />Type of Business or Prope <br />G� • <br />BUSINESS A1..TAF—= SA 6r hJ <br />FACILITY ID <br />b00 ugg5 <br />�' <br />MAILING ADDRESS / �L <br />SERVICE REQUEST # <br />CITY STA7E 7JP � 7 <br />OWNER/ OPERATOR A <br />O <br />BILLING PARTY Cl <br />FACILITY NAME � <br />SrrE ADDRESS <br />Stet Number <br />Direction <br />/ <br />SVw Nxm <br />7yp� <br />SuH� f <br />Mailing Address (If Different from Site Address) <br />1140 <br />r <br />u <br />CITY 11lJ ' <br />STATE Zip <br />PHONE #1 EXT. <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 UT. <br />BOS DISTRICT <br />FT k <br />LOCATION CODE' <br />_ <br />N19Hly;•flAN1.60l2:417IN=UI 1I11� taI 7 <br />REQUESTOR � � � � BILLING PARTY <br />BUSINESS A1..TAF—= SA 6r hJ <br />PHONE# <br />�' <br />MAILING ADDRESS / �L <br />FAX # <br />/LO <br />CITY STA7E 7JP � 7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have preps Ibis app)' on and at the work be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE: �[ <br />PROPERTY / BUSINESS OWNER D OPERATOR/ MANAGER D OTHER AUTHORIZED AGENT <br />If Apmcmr is not the B4Lm PAATY. prtwf of authoruatlon to sign is required Title <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 data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: WT <br />COMMENTS: /) _ P^`/n <br />R/E`ClEJ\/lEr D <br />J AN 3 1 ZOO5 <br />SAN JOAQUtN COUNN <br />HTtEW jRj DEPAR MENT <br />INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br />APPROVED BY:. n EMPLOYEE #: Qk(J DATE: 1-3 <br />_ 2 ID 5 <br />ASSIGNED TO: EMPLOYEE#: 93 <br />00q <br />3SY14) DATE: I ` �JI—D <br />Date Service Completed (if already c p ed): 1 <br />SERVICE CODE: PIE: <br />Fee Amount: o4 Amount Paid Payment Date j/17 <br />• a� <br />Payment Type Invoice # Check # /ly8j-j- Received By: <br />�01 <br />