Laserfiche WebLink
0 <br />FACILITY ID # <br />RECORD ID # <br />SERVICE REQUEST <br />INVOICE # <br />(SERVREQ) Revised 8/23/93 <br />rACH 1TY NAME ��/�,.��� ��� f�rBL%_ BILLING PARTY Y / N / <br />SITE ADDRESS _;;� ©© �25T1 yy� <br />CITY CA CA Z1PJ6�/`y" <br />OWNFR/OPERATOR 7" BILLING PARTY /Y / N <br />DBA PHONE #1 (Z- � ) y�ZZ-- 92t-- Z_ <br />ADDRESS " • - %, ✓ a PHONE 02 ( ) <br />CITY yeti STATE ZIP <br />APN # — Land Use Application # <br />I IF <br />BOS Dist I Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR Jim Thorpe Oil, Inc. BILLING PARTY Y / N <br />DBA Rich -Mart Construction PHONE 1111 (209 ) 368 -6175 <br />MAILING ADDRESS P.O. Box 357 FAX # (2209 )368 - 1851 <br />CITY Lodi, Ca 95241-0357 _ STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/EHD 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 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes ar<J_.Si:andards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />Title: <br />Owner <br />Date: 3/4/94 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, 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 />environmental/site assessment 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 provided to me or my representative. <br />Nature of Service Request: <br />AScigned to <br />Date Service Completed _/_/ <br />Employee # �f[V <br />Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RFHS _/ / SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />