Laserfiche WebLink
SERVICE REQUEST <br /> .,.. � r00REG) Revised 8/23/43 <br /> tACIL1TY ID N \ RECORD 10 N INVOICE N <br /> FACILITY NAME Z r"O r � //�i �p r I flp� TIP /S 7- {��/�O� -p^,-� BILLING PARTY Y / N <br /> S I TE ADDRESS N.LAJ . 1N 1�7v E 1`J ��Gl !'d'IA/y .5.3 ')- U eyll!L L/ -,� 7, <br /> pp ���� <br /> CI7Y �/`f+L `6A-/ ZIP <br /> OWNFR/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE N) ( ) <br /> AODRESS PHONE N2 ( ) <br /> CITY STATE ZIP <br /> �APN N p Lard Use Application N <br /> 7{n-- I 11 BOIS Dist Location Code <br /> r.nNTRACIOR <br /> SERVICE REGUESTOR Vim, 1.� I/�-/ "`✓J b� ._L.1 1` BILLING PARTY Y / N <br /> DBA � 7 ! ' PHONE NI ( ) <br /> MAILING ADDRESS 1 V• I✓�IS`/IC ��C T FAX N ( ) <br /> CITY nI�ES 1 (.1 STATE ZIP 61S 3�7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that sit site and/or project specific <br /> PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Page t of this form. <br /> 1 also certify that I he" 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. PAYMENT <br /> APPLICANT'S SIGNATURE REcEIVED <br /> Title: Date: <br /> MAY 1 9 1994 <br /> SAN JH LTH SERVICES nn <br /> A111 NORIZATION 70 RELEASE INFORMATION: In addition to the above, when eppal�f�e tR=1 tN "C*tJH0VA %r agent of same, of <br /> the property located at the above site address hereby authorize the cele . Ty and all results, geotechnical data ardor <br /> environmental/site assessment informetien 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: }�IService Code <br /> Assigned to 11`ti� T GIS Eaployee N e Date <br /> Date Service Coapleted / 1 / / Further Action Required: Y / N PROGRAM ELEMENT J--6O, - <br /> /Fee Amntn/tt Mount Paid Date of Payment Payment Type Reoj N Check N Recvd By <br /> RFHS _/ /_ SUPV _/ /_ ACCT _/ / UNIT CLK /_/_ <br />