Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID 0 RECORD ID # G INVOICE # 1 3LP4-1 <br /> FACILITY NAMEcoff& l /�/q/✓ gI LLING PARTY Y / N <br /> �0 i! <br /> SITE ADDRESS 1 <br /> �l <br /> CITY CA ZIP <br /> I <br /> V <br /> OWNER/OPERATOR BILLING PARTY Y / N �p <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 <br /> I <br /> CITY STATE ZIP <br /> APN # FLand Use Applicati on # ,1 <br /> BOS Dis[ Location Code <br /> !I <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ✓ ! !l2 'F1���,/�"UT/'/Pi Y/�I2-�/}y/ ) BILLING PARTY <br /> DBA ///`—�� `"/<✓" Jol J7�tz�l//'^v' ( ",,C7Z//- �f PHONE #1 <br /> MAILING ADDRESS . -7�" T — -� V1 � / r 1/� "/? FAX # ( ) <br /> CITY l V� a a STATE "r' ZIP <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 wit( be billed to the party identified as the BILLING PARTY on - <br /> Page 1 of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all 11AN <br /> JOAQUIN COUNTY Ordinance Codesandtandards, StateLnMdlederst laws. <br /> � <br /> �(^ E;Ij <br /> APPLICANT'S SIGNATURE - <br /> Date: tb aplz APR 1 0 1997 <br /> SAN <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ownef;;QQ1trU l.Ffry ag t f same, hf <br /> the property located at the above site address hereby authorize the release of any and aS�Vfg�iQS`¢F 1'Iqq��e�ht(3 �tVldaEa and/ojr <br /> environmental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALAQ6t!.I Sas soon as <br /> it is available and at the same time it is provi to me or my representative. Vi$I�N iIt <br /> Nature of Service Request: Service Code <br /> Assigned toS2) Employee # O yJ Date /�_/ a SII <br /> 1 <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> r <br /> ij <br /> i <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -71 <br /> .j <br /> RENS / /_ SUPV ACCT / <br /> /� f_[__ UNIT CLK <br /> it <br />