COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # I I RECORD ID # I Cl ! W / I INVOICE # �/,;z Cq FACILITY NAME Ey — BILLING PARTY Y / N 71 SITE ADDRESS (P�D 33 p! `C'If=fG t4\Vf CITY 5r��o N CA ZIP 952-07 NER OPERATOR +'I CAe `1 "�' 0-12 " k"' r BILLING PARTY Y / N OW DBA CH r --\/P,0 t` F1Z4 au C T 5 CO. PHONE #1 (910 )_pf-�2 - I Sco ADDRESS PO ' S 90gA- PHONE #2 ( ) Frr CITY 5P►0 ` '��N STATE C~ zIP ()4-5V35 r,= APN # Land Use Application # I ir BOS Dist Location Code CONTRACTOR and/or _ SERVICE REQUESTOR �-' W E N BILLING PARTY Y / N DBA IBJ at4t O (9jpyc MAILING ADDRESS � 2.s CITY SToC1c_.Tb PHONE #1 ( Z —) STI - 5I0 FAX # (—)-- STATE ) STATE CA zIP 9 5105 BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/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. I 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 Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: M G CL • Date: AUTHORIZATION TO RELEASE INFORMATION: In addition toRFbover,when appticable�,-I",`-fhe owner, operator or agent of same, of the property located at the above site address hereby authorize the glegsq any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUx, dUBL HEA% ISERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to ap!�brepresentative.-3 1 ��'�• hA iT b L Service Code Nature of Service Request:- / Assigned to I'r l� Employee # / Date / / Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMEN C? Fee Amount Amount Paid Date of Payment Payment T Receipt # Check # Recvd By RENS I PA/Z Az:�J SUPV -�—/ / I ACCT I b ��1 a -_ I UNIT CLK I _/ /