REMOVAL_1995 - Laserfiche WebLink

Home Browse Search

SERVICE RECUEST CEN 00 611 Revised 8/23/93 FACILITY ID # RECORD ID # 1 INVI3ICE # E� r PARTY FACILITY NAME Y ! N r} n, � �� - R EC D��,�G ir�'� -'rru� a 11�t 3 3 SITE ADDRESS AY 2 2 1595 CITY CA ZIP S f�� Ully CC v�l� �� '��•� � PUBLIC HEALTH SERVICES _ �EINNViR�LQANNMMEN�TIA' 1 OWNER/OPERATOR DBA ADDRESS , l l l u ` I ` PHONE #2 STATE V`'14 ZIP _ `f CITY APH # Lard Use Application # Location Code SOS Dist s =j CONTRACTOR and/or �y _.'l J BILLING PARTY Y N SERVICE REQUEST iN PHONE 41 FAX MAILING ADDRESS STATE `'V I ZIP 1CITY no BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific to the party identified as PHS/EHD hourly charges associated with this facility or activity Will be bitted the BILLING PARTY on Page 1 of this form. PAY}►y�1�� j". I also certify that I have pr red this app is tion and that the work to be performed will be do rarzegg with alt SAN JOAQUIN COUNTY ordinance Code standar s ate^and`Federal Laws. MAY 2 A 1t]��I MAY F+ :1 APPLICANT'S SIGNATURE UBL1C HEALTH SERVICES '. Dates _ r EALTH D VISION Titte- o£ when applicable, I, the owner, operator or agene't rt AUTHORIZATION TO RELEASE INFORMATION= In addition to the above, of sip any the property Located at the above site address hereby authorize PUBLIC{HEALTHease fSERVICES ENVIRONMENTAL 9HEALTHnDLVISION assoon as,- envirormental/site assessment information to SAN JOAQUIN COUNTY re � . It is available and at the same time it,is provided to me or my representative. , - service Code ? Nature of service Request: ti 4 Employee Assigned to Further Action Required: PROGRAM ELEMENT Date Service Completed !^� Recei t# Check# Rec�uBY L Fee Amount Amount Paid Date of Payment Payment 3 P RENS ! !' SUPN T,l ACC Sr UNIT CLK : -