REMOVAL_1997 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (EH 00 61) nRevised 8/23/93 FACILITY ID # RECORD ID # l / S� INVOICE # FACILITY NAME SITE ADDRESS �/;V,Z Ari CITY GYI CA ZIP /�Z d • �� OWNER/OPERATOR DBA ADDRESS BILLING PARTY Y / N N PHONE #1f( / Ave,! tel ✓ L PHONE CITY STi'i�TDyL STATE �_ ZIP 1SQ.D S APN # — Land Use Application # BOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR �/V BILLING PARTY / N i DBA PHONE #1 ( 711,),371- -S MAILING ADDRESS S , 7Y.' v 2^r' CITY IN J e!92G,r�l7% eZV FAX # (JVK1—) 321 " 2-3/ 2! - STATE Z�9— ZIP Z�6 yZ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, St aro Feder —taws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. i Nature of Service Request: 7 f v/ i r r i o Assigned to Employee # a�(/ Date Service Completed / / Further Action Required: Fee Amount Amount Paid Date of Payment Payment Type hh�r RENS SUPV _/ / IACCT / N Service Code Date _ v /_�/ _/ 6�. I PROGRAM ELEMENT Receipt # Check # Recvd By > `/ UNIT CLK