REMOVAL_NOV 1994 - Laserfiche WebLink

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SERVICE REQUEST (SERVREO) Revived 5/13/43 ILITYID # RECORD ID # BILL iNG PARTY Y/� F, FACILITY NAME SITE ADDRESS /�CJO L l�/ G T�J2- ('•` - CITY L CJ 3� l A ZIP OWNER/OPERATOR ::T-I /"AI U/-M,��[1h/.r/ /.�/Z/CC BILLING PARTY ( Y N DBA T PHONE #1 (,2,C1,9 ) 3 3- f Oce p -{ ADDRESS C-(c0E" V/C %�Z- /G� [� PHONE #2 ( ) CITY D '� / STATE ZIP IC.S L/4 — APN # Census --------- BOB Dist Location Code City Code ----- ~ CONTRACTOR and/or SERVICE REQUESTOR �'TY/C/, G-f-/� • -S/�J C GSC//�r /SIC. BILLING PARTY Y N DBA p PHONE #1 (;70 MAI41NG ADDRESS /`�� L/ X �C� O FAX # ( CITY STATE ZIP 5.5~,2-y / BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or proje:t specific PHS/EHD. hourly charges associated with this facility or activity will be billed to the party identified as the BILLINr: PARTY on Page 1 of this form. I also certify.that I have prepared this application and that the work to be performed will be done in accordance wit all SAN ' JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition 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 data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION .is soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code Assigned to Employee # Date Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS _/ /_ SUPV _/_/_ ACCT _/ /_ UNIT CLK _/_._