Laserfiche WebLink
1%. SERVICE REDUEST kjj / (SERVREG) Revised 8/23193 <br />FACILITY ID / RECORD ID A INVOICE R <br />FACILITY NAME I�J6/rlrROU <br />C� BILLING PARTY Y / <br />S <br />SITE ADDRESS _ . r11 I/. OUf 6dn _JI (Pel / l PF(%(L <br />CITY Sfa x CA ZIP �i' t/ �_1 7 <br />(MFR/OPERATOR &hir FII BILLING PARTY Y / 4D <br />DBA PHONE k1 ( O�f) -29 K <br />ADDRESS _ l 1��; /V�� TU 1)(L)4!,'i , I/ Wt 3d V /� $,HOME M2 ( ) <br />CITY �l�C>(, STATE \ ZIP <br />N p Lend Use Applicatfon I <br />IBOS Dist Location Code <br />CONTRACTOR and/or O(� <br />SFRVICE REOUESTORY11ry1 1 LQTV.t/ <br />DBA <br />MAILING ADDRESS -P 7S-0 V Aloft <br />BILLING PARTY / N <br />PHONE Mt ( q1L )_`fSS- - 7�-1Z <br />CITY SQ(rQMr/1F'O STATE 074 -_ ZIP ?Sy I <br />FAX N ( 116 )'i8s -O4 <br />Al LLIRG ACKNOULEDGEMENTt 1, the undersigned owner, operator or agent of acme, acknowledge that sit site and/or project speclfle <br />PNS/END hourly charges associated with this facility or activity will be billed to the partyRoof"N,fhe BILLING PARTY on <br />Page 1 of this form. nnRF�ECe1VLC <br />I nlso certify that 1 have prepared this application and that the work to be performed wit P C*7dA95nJW4rdence with all SAN <br />JOAQUIN COUNTY ordinance Codes and Standards, State and Federal laws. PUBLIC <br />SAN <br />EAIL H OUNI E5 <br />APPLICANT'S SIGNATURE <br />(1 ENVIRONML,NTAL HEALTH DIVISION <br />�X�-• <br />Title! clia&' Date:_L0���� <br />AIItIIoR IZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or pent of same, of <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 Infornmtion to SAN JOAQUIN COUNTY PUBLIC HEALTN SERVICES ENVIRONMENTAL HEALTH DIVISION as coon as <br />It Is available and at the same time It Is provided to me or my representative. <br />Nature of Service Request: jj�� . ' II // Service Code <br />Assigned to OL K- (A -(,t e1�- <br />' ,.- Employee N � � � � Date —/—/ <br />n E7 <br />Date Service Completed / / Further Action Required! Y / N PROGRAM ELEMENT X -�,> <br />tee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check B <br />Recvd By <br />a�.00 <br />sg <br />Z ble-1 I <br />q7FLI <br />SUP V _//_ ACCT // UNIT CLK _/_/_ <br />