Laserfiche WebLink
SERVICE REQUEST �..► (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME VI -I [BILLING PARTY Y / N <br /> SITE ADDRESS I G�T>Y� '� 5--Cl D <br /> CITY r✓41/ti,ab CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or 1 <br /> SERVICE REQUESTOR '1 A r BILLING PARTY Y / <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <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 <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 done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, St, te and Federal laws. <br /> APPLICANT'S SIGNATURE MAR 19 1996 <br /> Title: Date: 6AN JUH(1UIfv <br /> E LLTH SERVICE,; <br /> CNVIR oper-% � iHb e �dfluema, of <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, open <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 same time it is provided to me or my representative. <br /> Nature of Service Request: jUi 7Lt /41�� 1�� Service Code <br /> f �r <br /> Assigned to I /� �r94r- Employee # �p Date — / 1v <br /> Date Service Completed / 2 �/ �C� Further Action Required: Y / [PROGRAM ELEMENT L-'s <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> El <br /> _/ / SUPV _/ / ACCT` G 3 / / UNIT CLK _/ / <br />