Laserfiche WebLink
0 SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # 3 / <br /> FACILITY NAME C�tC�—V ` BILLING PARTY Y / <br /> SITE ADDRESS 2qO6 —�1Ja�M�� <br /> CITY -915TCC-V-1-n--L CA ZIP <br /> OWN OPERATOR Civ yr)� BILLING PARTY G Y / <br /> DBA lJ^''" PHONE #1 <br /> ADDRESS d• � PHONE #2 ( ) <br /> CITY � 1T'" STATE (fit ZIP <br /> APN # Land Use Application # <br /> er, ^ / _ BOS Dist Location Code <br /> CONTRACTOR land/or r <br /> SERVICE REQUESTOR 1� / /T � ��' �IT�— BILLING PARTY / N <br /> DBA _ Com/ � Y�/ dLtr i ct{�LL PHONE #1 ( 15-1 <br /> MAILING ADDRESS t J r ►`+� C �✓`� '� V{i• FAX # <br /> CITnt5l-k STATE CA ZIP { �� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <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 /> 0199, <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 and Standards, State and Federal laws. <br /> PUBLIC HEAL <br /> APPLICANT'S SIGNATURE NVIRONMENTAL HI {! <br /> Title: Date:_ �C� 9. 19V <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 /> T Service Code 7 <br /> Assigned to __t/ (dLyJ��� Employee # Date 4(�—/ /1) _/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �a3`f� �o�ld Gj /8S10 J <br /> RENS _/ / SUPV _/ / ACCT ILP ��/ /� /� UNIT CLK _/ / <br />