Laserfiche WebLink
N ;FRVICE REQUEST <br />Type of Business or Property <br />CAL STAT"(_ En)blAl�-E(al 1\(IfQC . <br />FACILITY ID # <br />PHONE # Ezr. <br />Oc) L4 I <br />SERVICE REQUEST # <br />tDENriAL' <br />CITY STATE ZIP `q pild <br />INSPECTORS SIGNATURE:n CONTRACTOR'S SIGNATURE: <br />APPROVED DY:. -� YEE#: Y <br />/ <br />DATE: Q+X? t <br />AsSIGNEOTO: EMPLOYEE <br />,9 9: <br />DATE: �nQ \�nFNZP <br />Date Service Completed (if already completed): <br />SERVICE CODE: j Z <br />pN <br />OWNER OPERATOR, <br />Amount Paid ' '... payment Date <br />BILLING PARTY 0 <br />I <br />(7�)��lV ( r1 S �Wl) <br />Z0013 <br />FACILITY NAME <br />SITEADDRESS <br />`�y351 <br />vl It�`�1y11�C <br />[� <br />oa Stmt Numbr <br />O4ectian <br />STrM N„n� <br />Type <br />Suft1I <br />MAling Address (If Different from Site Address) <br />�s �. �.� �I� P►To� VE <br />C1rY, <br />.WLs5, E ( <br />STATE ZIP <br />Cts '9 sip C l <br />PHONE#1 Exr• <br />APN# <br />LANoUSE APPLICATION# <br />( <br />00q — 3UO— 09. • <br />PHONE #2 EXT. <br />BOS!DISTRICT <br />LOCATION CODE' <br />CONTRACTORISERVICE REQUESTOR <br />REQUESTOR BILLING PARTY 0 <br />CAL STAT"(_ En)blAl�-E(al 1\(IfQC . <br />BUSINESS NAME <br />'5(\rne <br />PHONE # Ezr. <br />Oc) L4 I <br />MAILING ADDRESS <br />y�� (�12OAD(�lA <br />FAX # <br />26 Z73-S8UL4 <br />CITY STATE ZIP `q pild <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 />PUBUC HEALTH SERvICEs ENVIRONMENTAL HEALTH DMSION hourly charges associated with this projector activity will be billed to me or my business as idenlified on this form. �\ <br />I also certiy that I have prepared this application and that the ork p rfo ed will done in accordance with all SAN JOADUIN COUNTY 0rdi nca Codes, fandards, STATE and <br />FEDERAL.Iaws. 2 <br />APPLICANT SIGNATURE: DATE: ` • J <br />PROPERTY/BUSINESS OWNER OPERATORIMANAGER OTHER AINHORI2EDAGENT J V'`� N 61 NE�12 <br />If Avrtftl yr is rat the ftiktarn Ixvof of Ialhaua!!on to sten Is rvqulr d- ` ri f I s <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 environmentallsite assessment Information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwtRONMENTAL HEALTH DMSION 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: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />u''% �►�-� �- c� ���- �� SEP 14 2000 <br />C�14 �\ - SAN JOAQUIN COUNTY <br />• J �/ E�,VwGc, ENVIRONMENTAL <br />INSPECTORS SIGNATURE:n CONTRACTOR'S SIGNATURE: <br />APPROVED DY:. -� YEE#: Y <br />/ <br />DATE: Q+X? t <br />AsSIGNEOTO: EMPLOYEE <br />,9 9: <br />DATE: �nQ \�nFNZP <br />Date Service Completed (if already completed): <br />SERVICE CODE: j Z <br />pN <br />Fee Amount: _ <br />Amount Paid ' '... payment Date <br />Payment Type Invoice k' <br />Check 7TReceived <br />By: <br />