REMOVAL_1996 - Laserfiche WebLink

Home Browse Search

�JJ .,.C ,/ i C- ?/ L SERVICE REQUEST LEH 00 61) Revised 0/23/93 FACILITY ID # RECORD ID # INVOICE # FACILITY NAME J.H. Simpson Company BILLING PAR1Y Y / C 4025 Coronado, Ave. SITE ADDRESS Stockton, 95204 CITY G ZIP OMR/OPERATOR J.H. Simpson Company BILLING PARTY Y / N DBA PHONE 01 ),yj��—•��,"_�— ADDRESS P.O. BOX 8640 PHONE #2 ( ) Stockton, CA 95 CITY STATE ZIP F APN # p Lard Use Applicata cn # II ROS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY Y / DBA PHONE #1 ( 2.09 ) �6$_- 6179 MAILING ADDRESS P.O. SOX 357 _ FAX III ( 209 ) -FAR -185 CITY Lodi, STATE CA Zip 95241-0357 BILLING ACKNOWLEDGEMENT: I, 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. YM ENI I also certify that I have prepared this application and that the work to be performed will be done ^i In taccordance with all SAN J JOAQUIN COUNTY Ordinance Codes ndards,�t6e and at laws. sAryJ N A t !JOU oa��_ APPLICANTS SIGNATURE : / "L 1 1 IRO TAL HEALTH DIV.IS!ON Title: Contractor 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 date 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. ,� Service Code Nature of Service Relquest: '�`-c;,,„ �/` Assigned to '-/ / 6 Employee # _ Date Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By G/c- RENS _/_/_ Y CL// Z / r ACCT _/_/_ UNIT