Laserfiche WebLink
SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />Amount Paid <br />RECORD ID # <br />Payment Type <br />Receipt # <br />INVOICE # <br />/;� ,V� 1 <br />FACILITY NAME N A BILLING PARTY Y / N <br />SITE ADDRESS Z S 7, <br />CITY S4txk4zoa, CA ZIP <br />OWNER/OPERATOR ,'1 �^ ^ � 1'�.t�Vth.ei['Tl BILLING PARTY / N <br />DBA 1%iW PHONE #1 (20ci <br />ADDRESS PHONE #2 ( ) <br />CITY C'C b_��-/ll/� STATE CIA <br />#F==Land Use Application # <br />ZIP `LJ WSJ <br />71 805 Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REOUESTOR �rr� I'/1i-Ili'l�9/N�++>'�'%� G�C/T�/C/t^�/rfH BILLING PARTY Y / N <br />DBA PHONE #1 ( ) <br />MAILING ADDRESS /6hy0 �J. kctHGZuorM Lw-lflo FAX # <br />CITY STATE Cil- ZIP 9s-z,�-/o <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that �yp r and/or project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party i[Ja i WILLING PARTY on <br />Page 1 of this form. fP'jj�E`'fel viep <br />1 also certify that I have prepared this application and that the work to be performed wilSAytr� �Y n eccbF24Me with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Stanands, State and Federal laws. PL18,16y <br />EMWROP4,1#r ti 'n1LJ <br />APPLICANT'S SIGNATURE C/ DILI`�61{p <br />Title: C)-� �^'�,t� Date: <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 <br />it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: Service Code U ✓ 1 <br />Assigned toALA Employee # 00 Date,��// <br />Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT -7,3.0 l.} <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />z34as <br />3� Fs -T <br />L6 <br />REHS _//_ I SUPV I _/_/_ I ACCT�YY//J/�/_ I UNIT CLK <br />\" <br />