BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

. - SERVICE REQUEST (EN 00 61) Revised 8/23/93 �I rACILITY ID 0 RECORD ID / INVOICE N I Katzakian Proper �`"- FACILITY NAME _------__ BILLING PARTY Y I SITE ADDRESS 15431 Lower Sacramento Rd. city Lodi , CA zip 95242 11 I� OITBER/OPEWOR Art Katzakian BILLING PARTY Y / N DBA PHONE 81 ( 916 ) 682 •3748 ADDRESS 10241 Sheldon Rd. PHONE x2 1-) CITY Elk Grove, STATE CA zip 95624 APN A' Lend Use Applicatf on s 1P I I BOS Dist - Location Code 11 CONTRACTOR and/or SERVICE REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY Y / DRA PHONE 01 ( 2..09 ) 168 -•6175 MAILING ADDRESS P.O. BOX 357 FAX / ( 209 ) -AAR -.lSrl CITY Lodi, STATE CA zip 95241-0357 BILLING ACKN018.EDGEMENTI I, the undersigned owner, operator or agent of same, acknowledge that all site and/or protect specific FHS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Page 1 of this, form. VVpp�� i �ATrvt I. I Also certify that I have prepared this application and that the work to be performed will be done In act l SAN '.. JOAQUIN COUNTY OrdinanceCodes or at Federal u H SEP 121997 APPLICANT'S SIGNATURE .- 7 11 I. ' PUB N JOAQUIN COUNTY - li Title: Contractor _. Date: 9/9/97 F"'VN UEI'aH ALHfA SERVICES VICESION' AUTHORIZATION TO RELEASE INFORMATION.- In addition to the above, when applicable, 1, the owner, operator or agent of soma, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data end/or environmental/afte assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon es It is available and at the same time It is provided to me or my representative. Nature of Service Request.- - Service Cask Assigned to Employee 0 note Date Service Completed _/_ / Further Action Required: Y / N PROGRAM ELEMENT II vi Fee Amotnt<1 Amount Paid Date of Payment Payment Type Receipt k Check N Recvd By i I LENS p —/_/_ ACCT —/—/—