Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> F <br /> FACILITY ID # . . RECORD ID p INVOICE # <br /> / / _ <br /> 62 Z <br /> FACILITY NAME S� T1 t" rW 1 ` 7T E. OILLING PARTY Y / <br /> SITE ADDRESS �✓��{ �, (1� 0 ` � <br /> QC <br /> CITY L V U l CA ZIP 1 J 1 <br /> OWNER/OPERATOR B 1 W f1 �F�� L� , BILLING PARTY / N <br /> DBA (Jy1 PHONE #1 (LI-63 ) 377 - 12-1-3 <br /> ADDRESS r ) �� 1� PHONE #2 ( ) <br /> CITY STATE (24 ZIP <br /> APN # Land Use Application # <br /> BGS Dist Location Code <br /> CONTRACTOR end/or Ll <br /> SERVICE REOUESTOR ---( '\' /)�� �,M BILLING PARTY LT�'�Y / CJ✓ <br /> DBA IJ'uL 1 EL ��)L-.{JCu��(��f�J}�t+Y� 1�q L� PHONE #1 "]—�— <br /> MAILING ADDRESS /�,,("��",�Afou " - ' t� TAX # (a. , ) 847- 7� <br /> CITY orV 4 STATE _ L ZIP -1 '73 )b 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. PAYMF-t-z <br /> 0 #-" ;. <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 Cod�s end Standards, State and Federal laws. SEP 18 1996 <br /> APPLICANT'S SIGNATURE TAN t JH(,)U IIV COU;' <br /> l 'I <br /> p > JBLIC HEALTH SERV! �' <br /> Title: �-'f ' I f.YEZ--� 1� Date: Ci I ( I �b','FZONMENTAL HEALTH DIVISIUr <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 <br /> it is available and at the same time it is provided to me or my representative.------------- <br /> i� <br /> Service Code l.' 3 <br /> Nature of Service Request: <br /> Assigned to L'� Vl? "Ployee # `4�C' Date �/-L'?-1 z_ <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ACCT _L._ UNIT CLK <br /> eu -' <br />