Laserfiche WebLink
SERVICE REQUEST (EN DO 61) Revised 8/23/93 <br /> RECORD ID 0 INVOICE M <br /> MILITY NAMEi, 1_1 \ ..l _C BILLING PARTY T / <br /> SITE ADDRESS rJ-70o r(-\,�A2_ <br /> CITY �C (x �L"�Z'Y�_ CA ZIP <br /> OWNEMPERATOR CQL�Ll111'1 L -� .0 BILLING PARTY Y / <br /> DBA �.�?��__t l .C PHONE 91 <br /> ADDRESS Y -�. ��CJTX �Li�� PHONE *2 ( ) <br /> CITYZ STATE _C, ZIP 1;1a5S:� <br /> F <br /> Land use Application C <br /> BaS Dist Location Coda <br /> CONTRACTOR and/or <br /> SERVICE REGIESTO—OR�v`�,/`\�C\,e'.��=�fj BILLING PARTY T �/( N <br /> DBA/fir Y 1 C�S 1 v� V l J 41 n J /. > Ste► PHONE 01 (�) -3"T�� <br /> MAILING ADDRESS 1 3W N FAX 9 (r4o�) P1 1 -0 3 <br /> CITY, STATE CA ZIP�5 <br /> . i <br /> =.BILLING AC33tOWLEDGEMENT: I, the undersigned owner, operator or agent of wee, acknowledge that all site and/or pra)ect specific <br /> PNS/EW 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 slso certify that I have prepared this application and that the work to be performed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal l-awwss.-( <br /> APPL I CANT'S SIGNATURE <br /> Title: �`� �.T� Date- /CJ /GO <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the about, 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 /> environwntnt/site assessarnt 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 <br /> provided to we or my representative. <br /> Nature of Service Request: 1"�1 Service Code <br /> Assigned to Employee # Date _/ .....Z2 <br /> Date Service Completed _J / Further Action Required: T / N PROGRAM 2LEMXNT J V� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt B Check B Recvd By <br /> J <br /> RENS _/ / SLAV _f_J ACCT __/_/ UNIT CLK �� <br />