COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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iSERVICE REQUEST • �1� SERVRE0) Revised 8/23/93 FACILITY ID 0 ,? (] RECORD ID # INV01 - FACILITY NAME BiLLING`P 2� -- b� SITE ADDRESS _� CITY CA ZIP t OWNER/OPERATOR BILLING PARTY Y N DBA PHONE #1 C6_16 � ) - l ?� /� J�� ADDRESS ✓ V �/" PHONE 02 ( � - CITYwc,;�Cuftj !STATE zIP 4S_74 APN # land Use Application # — 90S Dist location Code CONTRACTOR and/or SERVICE REQUESTOR r �J 81LLING PARTY Y / O DBA _ PHONE #1 (fJ�Q)�,' MAILING ADDRESS FAX # ( " / ) � CITY STATe 1 _ ZIP BILLING ACKNOWLEDGEMENT: I, 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. 9 9 1995 Sf` , ,,,��„a�� f YJNTY I also certify that I have prepared this application and that the work to be performed will be done j gecordence with all SAM JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. [ APPLICANT'S SIGNATURE Titte:±:-!� Crtrn��:4e Date• J-19- 9s- AUTHORIZATION TO RELEASE INFORMATION: In addition to the ebov,a, when applicable, 1, 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. Nature of Service Request: Service Code 3 I Assigned to tJ Employee # _(� Date Date Service Completed / / Further Action Required: T / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 3 REHS _/ / SUP _Jw J�_. ACCT `" UNIT CLK �_f