Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # �KW d�� a 3 INVOICE # <br /> BILLING PAR <br /> / 1 <br /> FACILITY NAME / //i� /7 l� �S1)Q�OYJ TY Y / N <br /> SITE ADDRESS 3 77`c]- 1�0 4 n ? 77/ <br /> CITY / CA ZLP 5 �53 A/] ' <br /> OWNER/OPERATOR / 1 )L 1� Y� /Y BILLING PARTY Y / N <br /> DBA \\ PHONE #1 ( S r,$yZ - 4 % <br /> ADDRESS /' D /J IX �' to fM L I�$ 1 PHONE #2 ( ) <br /> CITY m(1 O.Y`l�DY\ STATE LN ZIP 7l_ l <br /> P APN # Land Use App Lication # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �— KY1nIl7li II _ BILLING PARTY Y / N <br /> DBA \ Z� , 1,� PHONE #1 ( 2.b9 ),��i- I <br /> Ylb <br /> MAILING ADDRESS 7 G� LJ�!�� <br /> �](1� •n `-'`; � FAX # <br /> CITY Lo&v STATE � ZIP R�Z4 2- <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE : 14arK SLLL. ) <br /> Title: (On Ar n < /�-J 11/7./ Date: / 2. /2g(7/� - <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 /> envirorventa L/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 <br /> Assigned to. �////L Employee # < `' Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS �aT(% /O1 SUPV _/ /_ ACCT _/_/ UNIT CLK _/_/_ <br />