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SERVICE REQUEST {EH 00 611 Revised 8/23/43 <br /> INVOICE # <br /> RECORD ID # <br /> FACILITYRM 1D # <br /> EN @�G <br /> PARTY <br /> FACILITY NAME / v REC D & to� rNa O I,•7 W <br /> SITE ADDRESS J- Pub � J 1 v L Y 2 2 1C9IJ5[ ,* LA <br /> L tiS 3 l <br /> CITY `tel T c- L`t � CA ZIP VIII C-'(7;:l NJ�` <br /> PUBLIC HEALTH SER ICES <br /> ENVMRONMFNTA _ � <br /> BILLING PARTY Y / <br /> OWNER/OPERATOR i w) <br /> PHONE #1 <br /> DBA <br /> �� � PHONE #Z <br /> ADDRESS <br /> STATES ZIP <br /> CITY <br /> APN # Land Use Application # BOS Dist Location Code <br /> i <br /> CONTRACTOR and/ 1 � _-) BILLING PARTY Y f N <br /> r� + <br /> SERVICE REQUESTor � I '� r� <br /> PHONE 91 <br /> } V ✓ G 1 FAX'#7 r-1 �5 <br /> MAILING ADDRESS —7---e <br /> ti ���� <br /> CITY <br /> Juyzk---- STATE 0 Z1P <br /> ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> BILLING <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as t�hoBILLING PARTY on <br /> Page 1 of this form. � Pt�Ylg� <br /> I also certify that I have pr red this app is tion and that to be performed will be don <br /> xifi=MFrP with all SAN <br /> JOAQUIN COUNTY Ordinance Code Stand res $ ate and MAY 2 2 1995 <br /> APPLICANT'S SIGNATURE y� UBLIC HEALTH SERVICES <br /> Date: 1 y EALTH DIVISION <br /> Title: �Y <br /> L <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to <br /> authorize,twhehe releasecoflanyland all esultpse,rator or geoteehnicalagent of datasandfoo <br /> the property located at the above site addressY <br /> as <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PB <br /> it <br /> ENVIRONMENTAL HEALTH DIVISION as soon <br /> it is available and at the same time it is provided to me or myrepresentative. <br /> Service Code <br /> Nature of service Request: q <br /> • / �/—�� <br /> EmDate <br /> ployee # <br /> Assigned to <br /> Date Service Completed / <br /> Further Action Required: Y / N =PR06RAMELEMENT <br /> Fee Amount <br /> Amount Paid Date of Payment Payment Ty Receipt # <br /> Gheck # Recvd By <br /> d <br /> ACG <br />