SU0000698 - Laserfiche WebLink

Home Browse Search

SERVICE REQUESTCEN 00 61} Revised 8/23/93 FACILITY ID # RE D ID -} INVOICE #ou 2 FACILITY NAME J BILLING PARTY Y / SITE ADDRESS �{ i CITY _ � CA ZIP a /OPERATOR +. ✓ 41* C-A-tel es BILLING PARTY Y DBA PHONE 01 (_ ADDRESS PHONE #' ( ) CITY STATE ZIP APN # Land Use pptication # BCS Dist Location Code t+ CONTRACTOR and/or SERVICE REQUESTOR AA BILLING PARTY 0Y / M DBA C�+'I�S.�Q PHONE #1 i ZC/�) 6 \• MAILING ADDRESS f.— FAX # ( } I CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned o"r, operator or agent of same, acknowledge that ell site and/or project specific PNS/EHD hourly charges associated with this faOL ity or activity will be bitted to the party identified as 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 wit[ be .jpraccordance EN T e with all SAN JOAQUIN COUNTY ordinance Codes and Standards, State and Federal laws. RICf'� E T APPLICANTS SIGNATURE (� Title: Date, PUR, J0A0L,1r1 Nry ' ENVIRO N,MEvr ALrNs��vrc�s AUTHORIZATION TO RELEASE INFORMATION; In addi0 on to the above, when applicable, 1, the owner, b r ArL$I°{offl&61Same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical defA and/or errvironmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available end at the same time it is provided to me or my representative. r Nature of Service Request: ft96iaLk S.= Service Code Assigned to Employee # o 7' Date Date Service CaapLeted —7 /—Z-�—/ Further Action Required: Y / C!V PROGRAM ELEMENT 7- I - Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By F 'REHS _/ / $WV _/� ACCT J / UNIT CLK ��