Laserfiche WebLink
SERVICEST S�lti O 5 00 61) Revised 8/23/93 <br /> FACT.ITY IDM RECORD IDN # <br /> FACILITY N..ME ' — ' /�~/� 81LLING PARTY 1 T) <br /> SITE ADDRESS <br /> 019-3 <br /> CITY 5>r-r',�� i CA ZIP <br /> OWNER/OPERATOR �'eAU!/✓ /T V/JeR— _ BILLING PARTY .y Y /���N�j <br /> DBA (S/SuPG QP�i !/Vli� PHONE k1O/ )'11/ -�J�L__. <br /> ADDRESS 1eZ6 IV Ot !7- II -sFiZ/El"�NT PHONE #7 ( ) <br /> CITY Zen,'0 STATE ZIP <br /> APN M LApplicatian p erFa <br /> �� <br /> Dist Locaei«, code <br /> CONTRACTOR and/or <br /> SERVICE REel1ESTOR BILLING PARTY Y / Q <br /> DBA PRONE M1 <br /> MAILING ADDRESS FAX N <br /> I <br /> CITY STATE ZIP <br /> J <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, ackhawtedge that all site ardor project specific <br /> PNS/END hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed wilt be done in accordance with all SAN <br /> JOAeUIM COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> PAYMEN'T <br /> APPLICANT'S SIGNATURE :X./l< < ✓ t-lig /"dam-'� LP RECEIVED <br /> Title:— <br /> COUNTY <br /> itle: ��N Date: /.�• J`�5-`� 11PR 13 1995 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator "er E$ <br /> the property located at the above site address hereby authorize the release of any and at( results, geoFkakVga�tHJ�T 4 DIVISION <br /> environmental/site assessment imormation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EMVIRONMENT*t.MNI1QohRiS as soon as <br /> it is available and at the sere time it is provided to me or my representative. <br /> r <br /> Nature of Service Request: ��i F Service Code <br /> Assigned to Employee # ^� 3 '�-- � Date <br /> r <br /> Date Service Completed �/ r� / /� Further Action Required: Y / ( N� PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type 1 Receipt F Check /f Recvd By <br /> G <br /> �REHS '�'V�/� SUPV _/_�, ACC!Jy <br /> Y <br />