BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (EH 00 61) Revised 8/23/93 RECORD ID # L� INVOICE # FACILITY ID # '/ I [ /�//J, \/ FACILITY NAME V a Ill � �� I�Vy 4- 7 /1ryh/nV /�I/J 7./� BILLING PARTY Y / SITE ADDRESS / /) � (^� C ' ,"- '-Te,2 Ll— // CITY 5-7-;,5 -�T7J�^ CA ZIP AE2ULJ OWNER/OPERATOR VG, DBAPHONE 01 ( Z0 C) t16 S-' 71-t Z I ADDRESS h U /T Y C�V PHONE #2 ( ) CITY y�T� CrLJ•^ STATE C—•� ZIP APN # p Land Use Application # IBOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR DBA PHONE #1� (�)G/( rs Ij7� (11- MAILING ADDRESS V Uj` Ll FFAX # (-;?(-),Y)(-;?(-),Y)(-;?(-),Y)u' CITY SZ'C`-lrfi�)✓t STATE C_/ ZIP / T2, I 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'A1 Y14 t. E N I also certify that I have prepared this application and that the work to be performed will be don Pftfbecor"e with all SAN JOAQUIN COUNTY Ordinance Codes and Standards State and Federal laws. �/7 MAR 14 1996 APPLICANT'S SI <vL'�l�/ N�/IbLIC HE-rN UUNry l Title: 9/ _ Date• L� ufNTAII-+��tTHONISfUA, AUTHORIZATION TO RELEASE INFORMATION: Ina it* on to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site addr ss hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information SAN JOAW IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it i provided to me or my representative. '1 Nature of Service Request: er,ice Code �p9 Assigned to \ Employee # r�> Date i i Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By Z 0`2 O v ` 7� REHS 4A[ /_ SUPV / / ACCT / �S _ UNIT CLK _/ /_