Laserfiche WebLink
SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />Amount Paid <br />RECORD ID # <br />Q 3 <br />INVOICE # <br />+ Check # <br />/0% <br />FACILITY NAME <br />SITE ADDRESS V�^� A�/� <br />CITY zNr `-� CA ZIP <br />BILLING PARTY/ 0 <br />OWNER/OPERATOR /5-17e C2,n /-�- �� �7 �LY' l% BILLING PARTY G7 N <br />DBA CV Y MC�LL / PHONE #1 t�Lx1 ) QJ� a7�0 <br />ADDRESS l y' Z d 16 / PHONE #2 �7C1- '3 L/ .- <br />//+ <br />CITY--%�'STATE "-� ZIP <br /># p Land Use Application # ` <br />IBOS Dist Location Code <br />CONTRACTOR <br />SERVICE RE <br />DBA <br />�70072� <br />BILLING PARTY 7 / <br />/ PHONE #1 ( - <br />)J - <br />MAILING ADDRESS 1,6 J ' Zd/,( ` / `% FAX <br />CITY <br />CITY 454X-11-1-1 STATE �� ZIP `� ✓�� <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codee�sand standards, State and Federal laws. <br />!/✓ <br />APPLICANT'S SIGNATURE : &-1)16) 5� <br />title: Date: <br />f `'UN 2 4 1998 <br />//��%i;`c-Z?YL %//� - <br />PUBLIC JOAQUIN C�O.0 <br />AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, oi��iOttM[gyHftaFRl of <br />the property located at the above site address hereby authorize the rethase of any and all results, geotechnicPE"Q&WOR <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my reprdrentative. <br />Nature of Service Request: �� p .w�-Pr✓V-'tl X I Service Code U - <br />Assigned to I)WtL�n 00-00,,, Employee # �� Date -rc_/ <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT T.. 3 p(t-- <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />+ Check # <br />Recvd By <br />�arale—/��Fl�c.B <br />L3 -4z - ? <br />✓ <br />/ / <br />* 55x3 <br />I\// _/ / <br />REHSI <br />L3 -4z - ? <br />SUPT <br />It <br />/ / <br />ACCT <br />I\// _/ / <br />UNIT CLK <br />_/�_ <br />