COMPLIANCE INFO_1999-2001 - Laserfiche WebLink

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SERVICE REQUESTJ2/6 (EH 00 61) Revised 8/23/93 FACILITY IDS# D '__� IRECORD ID # INVOICE # •AGILITY NAME d- BILLING PARTY Y / N SITE ADDRESS CITY .<�� "�`Tti CA ZIP,?-5- OWNER/OPERATOR IP` -5-OWNER/OPERATOR BILLING PARTY Y / N DBA PHONE #1 ADDRESS PHONE #2 CITY STATE ZIP APN # Land Use Application # BOS Dist Location Code CONT and/or SERVICE REQUESTOR6'&F.7D2C T� 'ARTY Y / N DBA C/ PHONE #1 (O'q ) Yee/- MAILING ADDRESS V-(Z>- a FAX # (PX q CITY STATE F ZIP Z U BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or active y will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that �have prepa ed thi application and that the work to be performed will be done in h all SAN JOAQUIN COUNTY Ordi es a Stan ards, State and Federal laws. R C & APPLICANT'S SIGNATURE 1 9 SAN JOAWN COUNTY T i t l e Date: - P�161 1r HEALTH SERVICES ENVIRONMENTAL 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 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 /itis prove�j to me or my representative. Nature of Service Request: i/� ` l��/ t Service Code t✓�. Assigned to -- `-C' _ Employee # J Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �Q Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS / /( SUPV _/ / ACCT _/ / UNIT CLK _/ /