Laserfiche WebLink
SERVICE REQUEST ✓ CEH 00 61) Revised 8/23/93 <br /> FACILITY ID.# ` RECORD ID # INVOICE # <br /> FACILITY NAME tJJ2CCD FC QA \l `S�jq BILLING PARTY �tY / N <br /> SITE ADDRESS �c�5 �� 1�QYv�wtcy Lay (� -7 <br /> CITY /per 1 C�K.,Q�bv1 � •CAA zip,.,q'IS ( J <br /> /OPERATOR �Q� C� \ t CX��`l� S �Gr7 to i-YVLI.f BILLING PARTY Y / <br /> DBA PHONE #1 <br /> ADDRESF? C7 ���X ��� PHONE #2 ( ) <br /> CITY �r�C-S LCA STATE �_ ZIP 4� ( <br /> PAPN # P Land Use Application # <br /> II BOS Dist Location Code <br /> CONTRACTOR and/or 1 <br /> SERVICE REQUESTOR -Tp �\ t `SU L (•�/�1c— BILLING PARTY ® / N <br /> DBA ' \ PHONE #1 ( ) <br /> MAILING ADDRESS _ C)0I CJia WLcn ''')1'}' FAX # <br /> r ( <br /> ( ) - <br /> CITY C��x.O <br /> O STATE CA zip ,4szn <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepare this application and that the work to be performed will be done�i A` 0t4of with all SAN <br /> JOAQUIN COUNTY Ordinance Codes Standards, State a F rat laws. `f IMC 1'� <br /> REGE.I�F� <br /> APPLICANT'S SIGNATURE Jun <br /> �i ¢G ►°GAIT ' �/"/S�- <br /> Title: Date 6Ah �; QAC;JIiv t�V�A`1' <br /> PUBLIC HEALTH SS�E"RVIIC�IES�S N <br /> AUTHOR IZATI N TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the o yF{QpgpHtMrTIAk�gencT�f"58N�,Oor <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <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 representative. <br /> Nature of Service Request: _�P!tL Service Code <br /> Assigned to y/Cl 5' l'(0k — Employee # ` nloU Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Z 3,(0 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �I b2 <br /> REHS / /_ SUPV _/ /_ ACCT` I+ 4-. / /_ �' ._ UNIT CLK <br /> 1. <br />