Laserfiche WebLink
'77J�� SERVICE REQUEST " I 1:3�:��SERVREC) Revised 8/23/ 3 <br /> rACTLITY ID N RECORD iD 0 OICE 0 <br /> FACILITY NAME V`� V` ' iL Q PA TY Y / N <br /> SITE ADDRESS � � <br /> z, d fil51(h <br /> 1 <br /> CITY � � CA 21P <br /> OWNFR/OPERATOR �Lsq BILLING PARTY / N <br /> DBA / PHONE #1 ( ) - <br /> ADDRESS PHONE #2 ( ) <br /> CITY &r0 f/ �/`�l STATE AX ZIP ' <br /> -APN # —Land Use Application 0 <br /> BOS Dist Location Code <br /> _._. <br /> CONTRACTOR and/or -177 r �Ti <br /> SFRViCE REQUESTOR AS �Q�j,`� /QV_T(y ", J BILLING PARTY Y / N <br /> DBA PHONE N1 (,Z�_) <br /> MAILINr ADDRESSy ) FAX ( ) <br /> i <br /> CITY / �j (/GS l ly' STATE d!J__ ZIP (LS , <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 /> Pnqe 1 of this form. <br /> I nlso certify that i have prepared thisIca n a t work to be performed will be done in accordance with ell SAN <br /> JOAQUIN COUNTY Ordinance Codes and Ste , to a a laws. <br /> APPLICANT'S SI ATURE : <br /> Title: Date: <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 /> environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the some time it is provided to me or my representative. <br /> 03 <br /> Nature of Service Request: �i�r�S(��� �GL! 1;'k <br /> Code ep <br /> l 54u r <br /> Assigned to Ji��� / �G 'Employee * D4' � Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt K Check N Recvd By <br /> RFHS / / SUPV / / ACCT / /���r UNIT CLK _/ / <br />