SU0000997_SSNL - Laserfiche WebLink

Home Browse Search

A 9 SERVICE REQUEST ....r (SERVREQ) Revised 8/23/93 FACILITY ID N RECORD ID 0 INVOICE R FACILITY NAME —,L 1-2 __ BILLING PARTY Y SITE ADDRESS e7Z2 4!�5 !J �� i (� f/✓�/I �CJ CITY CA ZIP ( � L-12 V1 nWNFR/OPERATOR Jr All /•,Qy��/��1 BILLING PARTY Y N DBA 6' GZ///S�L /- �3 PHONE Mi ( ) ADDRESS �aC�J ��LI �O PHONE 02 ( ) CITY �y1S STATE ZIP _3 J APH 0 — F Land Use Application N �� j �s BOS Dist Location Code CONTRACTOR and/or /G SERVICE REOUESTOR / �+C� -�G 'l BILLING PARTY y M DBA /Yr ��z �- PHONE MAILING ADDRESS / �i /� ��1 zp- ( � 2 FAX CITY STATE STATE ZIP RILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identified so the BILLING 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 with all SAN JOAQUIN COUNTY Ordinance Codes and �Standards, State and Federal laws. APPLICANT'S SIGNATURE Title!—/ 7/l�-! �i� � Date: /2-- Lf— F� AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 as 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 A �j `T Date Date Service Completed �! / ' Further Action Required: Y PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receip�-#V Check N Recvd By REHS / / SUPV _/ / ACCT UNIT CLK Pt� --t� Fc( (� 3 - & C