Laserfiche WebLink
SCANNEiO�(-)(4 1(4 <br /> (Y e I SERVICE REQUEST iEH 00 61) Revised 8/23/93 <br /> —]— <br /> [FACILITY ID # RECORD ID # INVOICE # oa-a(� <br /> FACILITY NAME BILLING PARTY Y <br /> SITE ADDRESS 6 5 " <br /> CITY CA ZIP <br /> OWNER/OPERATOR rte P-,0i 7'` 1314 CA-t^ �G �� BILLING PARTY Y <br /> DBA PHONE #1 ( ) �� <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> FAPN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR /yC)(� �-Z=!moi BILLING PARTY / N <br /> DBA PHONE #1 ( Z G C-I) 2/nk U <br /> MAILING ADDRESS 3 1,AJ , 6L Le s FAX # ( ) <br /> r <br /> CITY STATE ZIP <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 f <br /> Page 1 of this form. _ <br /> I also certify that I have prepared this application and that the work to be performed will be yl1V accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. Fr'AA M E N T <br /> APPLICANT'S SIGNATURE I 111J <br /> (n <br /> SAN JOAp(_,1' <br /> Title: Date: PSI (JkINTY <br /> ENVIRp"M HEALTH SERVICES Z <br /> ENTdL� Igf same, of <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, o <br /> the property Located at the above site address hereby authorize the release of any and all results, geotechnical d1a 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 /> , <br /> Nature of Service Request: Service Code <br /> Assigned to a-1-D I Employee # � Date <br /> Date Service Completed / /�� Further Action Required: Y / UL) PROGRAM ELEMENT T_ , Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT �/ /�/II� UNIT CLK <br /> 1 <br />