Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FFACILITY ID # <br /> RECORD ID # O 5/ <br /> 7�IN`VOICE <br /> �Af BILLING PARTY Y / N <br /> FACILITY NAME �7 o H <br /> SITE ADDRESS <br /> CA ZIP <br /> BILLING PARTY Y / N <br /> OWNER/OPERATOR VVV��\Ysl/ <br /> PHONE #1 ( ) <br /> DBA <br /> y� \� PHONE #2 ( ) <br /> ADDRESS /JL�J�' <br /> CITY 1:7C/`�_��-�"" STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist location Code <br /> ONTRACTOR and/or <br /> /_./ -^, E���� <br /> N <br /> ERVICE REQUESTOR l <br /> PHONE #1 ( ) <br /> DBA <br /> FAX # ( ) <br /> MAILING ADDRESS <br /> CITY STATE ZIP <br /> ame, acknowledge that all site and/or project specific <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of s <br /> PHS/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 /> `atl SAN <br /> I also certify that I have prepared this application and that the work to be performed will be done in acc IV g99 <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taus. <br /> FEB - 31947 <br /> APPLICANT'S SIGNATURE :_ <br /> SAN JOAOUIN COUNTr, <br /> Date: A� 'EALTH SERVICES <br /> T i t le: ENVIRONMENTA I�F <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or a�eh't -/ET W113f0M <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 /> Service Code <br /> Nature of Service Request: <br /> Assigned to / lj�l.�Gu^'l l� Employee # Date --7 / _/�/ <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT 7 3 D <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 41111111 <br /> REHS �/ / <br /> SU PV / / ACCT a/ <br />