Laserfiche WebLink
FACILITY ID # <br />FACILITY NAME <br />SITE ADDRESS <br />RECORD ID # <br />SERVICE REQUEST <br />(SERVREO) Revised 5/13/93 <br />BILLING PARTY I / Y `, / N <br />CITY CA ZIP e��7��D (� <br />OWNER/ ERATOR�C-CT�K� �T�!� BILLING PARTY Y N <br />DBA PHONE #1 ( Z !_i . <br />APN # <br />ADDRESS L—lf-t L���C +�'L� R �C PHONE #2 ( ) <br />CITY 4,r_)o STATE ZIP l• { <br />Census --------- BOS Dist Location Code City Code ---- <br />CONTRACTOR and/or <br />SERVICE REQUEST OR ���C. *Jai .-- _i'aL�C:� 1�}"C7C� �C✓,.�4Y.; BILLING PARTY Y / N <br />DBA PHONE #1 (�' 9C 4-�- F�� <br />MAILING ADDRESS i���C t� FAX <br />CITY r�;1-04n: STATE C—i+ ZIP .�Z_Z <br />BILLING ACKNOWLEDGEMENT: I, 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 preps kation and that the work to be performed will be done in accordance with all SAN <br />JOAOUIN COUNTY Ordinance Code an tandar State end Federal laws. <br />APPLICANT'S SIGNATURE : <br />C • P <br />Title: <br />Date: // // _q C1 <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: ��% �`� Z. ^ Service Code — <br />Assigned to Employee # a e lL/ 7 <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 />REHS _/ / SUPV _/ / ACCT _/ / UNIT CLK _/ 1 <br />