Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SERVICE $E9lJEST,t�— (EH 00 61) Revised 8/23/93 <br /> =FACILITY # ."�! 2, C RECORD ID # `3 �S� '� - �`11 INVOICE M <br /> L i/d. D3zcf <br /> FACILITY NAME PACIFIC BELL, -- --� � 1 BILLING PARTY Y / N <br /> SITE ADDRESS 1413 BOURBON STRF.'F7p <br /> CITY STOCKTON CA ZIP <br /> OWNER/OPERATOR PACIFIC BELL BILLING PARTY Y / N <br /> DBA PHONE #1 (-510 >823 - 7777 <br /> ADDRESS PO BOX 5095, RM 1N200 PHONE #2 ( 415 1331 . 0924 <br /> CITY SAN RAMON STATE CA Zip 94583-0095 <br /> �APN # p Land Use Application # BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR PACIFIC BELL BILLING PARTY Y / N <br /> DBA ATM: RICHARD JOHNSON PHONE #1 ( > <br /> MAILING ADDRESS PO BOX 15038 FAX # ( ) <br /> CITY SACRAMQM STATE CA ZIP 95851 <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 prepared this application and that the work to be performed will be done in accop4pnVI1 SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, <br /> State and Federal laws. PErF PAF n <br /> APPLICANT'S SIGNATURE : iC1f.L.�.�� AUG 2 g..a9gg <br /> -�NYG EN, A= <br /> Title: PRQTE(-'P MANAGER/ARONSON ENGINEERING,IN(B,t.; 8/19/96 6AN JOAOOIN MA- , <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent 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 information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as,W11 <br /> 011 <br /> it is available and at the same time it is provided to me or my representative. (' <br /> Nature of Service Request: Service Code <br /> �(:InS all <br /> Assigned to Employee # � Date —I—/— <br /> Date <br /> /Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 3 . y <br /> Fee Amount Amount Paid Date of Payment Payment <br /> /Type Receipt # Check # Recvvdd �By <br /> REHS _/ !/_ SUPV _/ /_ ACCT UNIT CLK _/ /_ <br />