REMOVAL_1994 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST ,.�. ) Revised 5/13/43 FACILITY ID # RECORD ID # BILL N PARTY / N 17) FACILITY NAME �S 1 0 � l'AL/� �T • ) SITE ADDRESS CITYN! G 7 GAJ CA ZIP S �� OHNE OPERA C C /0-0 ,r doklc ING PARTY it �/ N DBA PHONE #1 ADDRESS �-V ©� /W C1a"UG, c�'f . PHONE #2 ( ) LITYrC St- �Drl3 swee;e' ` ZIP APN # Census ----•---- BOS Dist Location Code City Code ------ CONTRA and/or, , , �r�y.�_ / , RVICE REOUESTOR6 �/ z�'L �^�-. 6,Ze BILLING PARTY DBA J� PHONE #1 ( ;?0,/ MAILING ADDRESS ��F/ Z)� y FAX # f CITlz M015 /J STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have preps ed th s application and that the work to be performed will be time in accordance with all SAN JOAQUIN COUNTY Ordinance s a Ids, State and jederal Federalws. APPLICANT'S SIGNATURE Title: S Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY 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. Nature of Service Request: Service Code Assigned to �l&/`�� JeAr-/rf`!= Employee # Date Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENTS dc Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By \ RENS _/_/_ SUPV _/_/_ ACCT ,�.-- /_/_ UNIT CLK _/_/_