COMPLIANCE INFO 1986-2001 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (SERVREG) Revised 8/23/93 TACILI TY ID N RECORD ID k INVOICE N Js ItiJ� ai „ Vrr// lA3Y� BILLING PART y / N rer.ultY wAHB 111/� W SITE ADDRESS CITY q57-33 (o {Y CA ZIP BILLING PARTY Y / N 161NF R/OPERA TOR PHONE MI ( ) DBA PHL)oE N2 ( ) ADDRESS CITY STATE ZIP . _AF--- L d Use Application N BOS Dist Location Code COHIRACIOR and/or �� , Cy �.ry; BILLING PARTY Y / N sFRVICE RFOUESTOR U PHONE N1 ( ) DNA //�� J' n `/�,, MAILING ADDRESS (2 l 3 `� , r WI �� Q FAX N ( p ) CITY � � �(� STATE 04- ZIP / �1 —�3 U RILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of acme, acknowledge that all site and/or project npeciflc plls/EBD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on roge') of this form. I nlso certify that I have prepared thin application and that the work to be performed will be done In accordance with all SAN JOADUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Date: Title: AIIIMORIZATION i0 RELEASE INFORMATION: In additl on to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or envirormental/Rite assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it Is available and at the same time It Is provided to me or my representative. Service Code Nm[ure of Service Requst: Assigned to Employee N Q 41 Date Det@ Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By �0- ACCT /_ _ / UNI1•CLK