COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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SERVRE WEST (SERVREQ) Revised 8/23/93 I'ArILITY ID # RECORD ID # /f INVOICE # rncn.tTr NAME �Edt'1 �i �� 7 BILLING PARTY Y / �� SITE ADDRESS l �u C / CA ZIP P 7 V(�yQ� J C 1 TY �f-( �� tttTNFR�PERATOR X�C�(� ��L1� BILLING PARTY Y / NJ DBA `-- X y/L) r1- PHONE #1 ( ) ADDRESS PHONE #2 (5d) ) - CITY l�Cil7CrO2 L STATE ZIP -APN # —Land Use Application # BOS Dist Location Code ..nNTRACTOR and/or SFRVICE REQUESTOR \-C er) l/`J�� IUU/�Z�j1IY�i1 BILLING PARTY Y / N DBA PHONE #1 MAILING ADDRESS �(0 FAX CITY ��U f'�2l'YL�12t STATE ZIP Rif-LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PIIS/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. 1 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 and Standards, State Federal laws. APPLICANT'S SIGNATURE TitIe: o-) Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of am*, 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:I"te—1 Service Code `( Assigned to �w VV` V Employee # Date _/ ZS / , e 2 Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ree Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By N 1- RFHST _/ / SUPV /__/ A CCT _1 / UNIT CLK _/ /