COMPLIANCE INFO_2001-2007 - Laserfiche WebLink

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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILItY ID # RECORD ID # INVOICE # FACILITY NAME CAle 1)6, 20I,76-1 BILLING PARTY Y J SITE ADDRESS CITY MOV14 e-lfa CA ZIP )WNER/OPERATOR ^P U ron, Pr a&V- E:B�ILL:ING PARTY Y / t DBA PHONE #1 ( )111 ADDRESS ly S S 5V&4e- C611e42 4AW PHONE 92 ( ) CITY drel- STATE GLI ZIP ZZ APN # Land Use Application #IF BOS Dist Location Code CONTRACTOR and/or —-- - — SERVICE REQUESTOR BILLING PARTY (Dy / 1 N DBA PHONE #1 (�),36-5- - /Z,z MAILING ADDRESS .Zh FAX # ( ZJ ) -_ZS CITY .C.®4t STATE (!14 ZIP 9,5 Y?— BILLING ZBILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on Page 1 of this form. I 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, State and Federal laws. APPLICANT'S SIGNATURE : 1 e Title:/ S /FIs 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. Nature of Service Request: Service Code Assigned to Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/ / SUPV _/ / ACCT _/ / UNIT CLK _/ /