Laserfiche WebLink
{ SERVICE REQUEST <br />FACILITY ID I ���, ' RECORD ID # I <br />FACILITY NAME CLI., .1% ` - 0- ;- <br />SITE ADDRESS <br />(SERVREQ) Revised 5/13/43 <br />BILLING PARTY I Y J <br />CITY <br />Amount Paid <br />CA ZIP �15ZZc�, <br />Check # Recvd By <br />�a3q <br />OWNER/OPERATOR <br />�--1� �1 ny 5 <br />BILLING PARTY N <br />kLl <br />DBA <br />ADDRESS <br />PHONE #1 ( ) - <br />PHONE aL (s —to ) 24-L- S(p <br />//•• Q <br />boi` `>a� <br />�D, �• box Sov <br />CITY <br />eAA (tftWNtkl <br />STATE _ ZIP <br />APH # <br />Census <br />--------- <br />BOS Dist <br />Location Code <br />City Code <br />------ <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />7 <br />3 ' BILLING PARTY ' ( Y) / <br />DBA t PHONE 11 (SCO <br />MAILING ADDRESS ��oc��\e FAX <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all�((S�l 0� oject specific <br />PHS/EMD hourly charges associated with this facility or activity will be billed to the party identity YLLING PARTY on <br />Page 1 of this form. R�''��±± 1 A q�DD <br />I also certify that I have prepared this application and that the work to be performed will be data & �Cc'�ida��d with all SAN <br />JOAQUIN COUNTY Ordinance ode nd Standar ral Laws. <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />APPLICANT'S SIGNATURE - ENVIRONMENTAL HEALTH L7IVlSiOh� <br />Title: Date: <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 ENVIRCMNENTAL 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: / df e Service Code <br />Assigned to moi" �% 1i e Employee # L h s / Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENTG7 <br />Fee Amount <br />Amount Paid <br />Date of Payment Payment Type Receipt # <br />Check # Recvd By <br />�a3q <br />3q <br />7 <br />REHS _/ / SUPV _/ / ACCT / UNIT CLK _/ / <br />