Laserfiche WebLink
SERVICE REQUEST r } 00c) Revised 8/02/93 <br /> FACIL77Y ID RECORD ID # INVOICE # ` <br /> FACILITY NAME BILLING PAR T N <br /> SITE ADDRESS +771 e/- S R Oy(/( <br /> CITY S f-r�ck fon CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Census --------- BOS Dist Location Code City Code ---- <br /> CONTRACTOR and/or _ , -, <br /> SERVICE REOUESTOR J/f'(/ b-ied BILLING PARTY Y / N <br /> DBA PHONE #1 ( 1U`] ) ! L3- —)C/.2 1 <br /> r ✓� �- Z O <br /> MAILING ADDRESS �'J 0%Gi1CI�/1 FAX 9 ( ,2(l ) <br /> CITY �/ U C At' STATE C .� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific V <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. 7t <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, State and Federal laws. �,J`(t <br /> APPLICANT'S SIGNATURE ^' Xl� V/�///�I <br /> Title: Date: <br /> � <br /> ��� r—? <br /> -� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/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: SO// SU/f �Je�drt t t M S - 9_3's_/__ Service Code <br /> i <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount /Amount Paid Date of Payment Payment Type Receipt # /Check # Recvd By <br /> Bim/ ! ��o• �j � -o�- �.� � �l� l�s //.� <br /> REHS _/ / SUPV _/ / ACCT _/,f UNIT CLK _/ / <br />