Laserfiche WebLink
SERVICE REQUEST <br />(EN 00 61) Revised 8/23/93 <br />FACILITY ID # <br />ocO 1—cJc,x <br />RECORD ID # <br />Payment Type <br />INVOICE <br />"TC <br />FAX# ( ) <br />CITY <br />C�,-�.G �� <br />6 -q <br />v <br />FACILITY 'NAMEi�`tZCQ �''QII CL \ CTC,I I�BILLING PARTY Y <br />1QYY�YL.0/ N <br />SITE ADDRESS �S1�j T'V— t aJ, <br />CITY _C�-t•-b .^ CA <br />/OPERATOR <br />DBA <br />ZIP Q'! 4Zt1 J <br />BILLING PARTY Y / <br />PHONE #1 (' ��)���- J 0'f <br />ADDRESS T C'1. 1�c�,X C.C)� ^ PHONE #2 ( ) <br />CITY 74TLC STATE \'ri ZIP 4�9 '2T <br /># Lard Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or I <br />SERVICE REQUESTOR �n L� �' 7Y SSU C_, (r) <br />DBA <br />BILLING PARTY ®/ N <br />PHONE 01 ( ) <br />MAILING ADDRESS <br />ocO 1—cJc,x <br />Lk)4-, <br />Payment Type <br />^1 (Tc <br />"TC <br />FAX# ( ) <br />CITY <br />C�,-�.G �� <br />6 -q <br />STATE CA <br />(�4 <br />ZIP —( 4+.SZC <br />i <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/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 Codes WIVAtandards, State argl/F#/bral laws. / <br />APPLICANT'S SIGNATURE <br />��,, // I PAYMENT <br />Tithe: Q %C -Dat gif �'�� 9j PFCEIVF0 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operatorJg4gen6 oy_A9&, of <br />the property located at the above site address hereby authorize the release of any and all results, rngeotechnical data, and/or <br />q `v rUL,ni <br />eirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVtRONNENTA H A'y� S� 01��s soon, as <br />it is avait.hi. and at the .. ti. it ie evnvidM to me nn my �oo�e�a..entf.,e buc Ll.. � I -, t_P1 V0.ao <br />Nature of Service Request: <br />Assigned to RC1 aVi,o S. <br />Date Service Cwpleted <br />Employee # �q GiS <br />Further Action Required: Y / N <br />.lar_we:nxAn�A.J <br />Service Code <br />Date / / <br />PROGRAM ELEMENT Z 3, /o O <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />6z4- <br />n,b'D <br />6 -q <br />ACCT <br />UNIT CLK <br />b?- <br />/'� <br />RENS <br />_//_ <br />SUPV <br />ACCT <br />UNIT CLK <br />