COMPLIANCE INFO_1997 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # �7 ��- INVOICE # / 7 FACILITY NAME ! /�z%� r BILLING PARTY Y / SITE ADDRESS CITY CA ZIP OWNER/OPERATOR BILLING PARTY Y / DRAW ga �/ U� PHONE #1 ( ) Z24v , ADDRESS r2-fs�+ "10 i �'/iuLN �QG PHONE 42 ( ) CITY G [��U STATE ZIP !�L/L• F APN # Land Use Application # BOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR /f [�/p�c/f1�.�.0 < � ` FBILLING PARTY Y / N PHONE #1 ( _) _' 4 + DBA G] / MAILING ADDRESS �7�T/ FAX # ( /t`6 ) LsSZ " 9�7J� CITY ZOOM`J STATE<' ZIP `J�f�✓ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, 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. P AIN N1 191 'VF-� I also certify that I have prepare thi plication and that the work to be performed will be done in ante AwiAth all SAN JOAQUIN COUNTY Ordinance Code St a ds St a F al laws. A p R 2 q 1a 77 APPLICANT'S SIGNATURE AN J• IAAPUBLIC HEALTH SERVICES Title Date. 91 0 n AL HEALTH DIVISION 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 envirorvnental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same timem it is provided to e or my representative. Nature of Service Request: �i4A1r —r1� S�tfi4T�.1GService Code DJT Assigned to 4 :-7 +i T— Employee # 6 p Date / / Further Action R =PROGRAMNT L s• f �✓ Date Service Completed / / Required: Y / N Fee Amount Amount Paid j _Date of Payment Payment Type Receipt # Check # RecvdBy l RENS / / SUPV _/ / ACCT _/ / UNIT CLK _/ /