COMPLIANCE INFO_1986-2008 - Laserfiche WebLink

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h,V SERVICE REQUEST (EH 00 61) Revised 8/23/93 RECORD ID # �Cj (!I INVOICE # FACILITY ID # PA MENTA ) FACILITY NAME F,46 L cer- W/ft BILLING PAJJJ1 / SITE ADDRESS Z SAN JOAQUIN COUNTY 7�( JL /� CA ZI P `Jro�D PUBLIC HEALTH SERVICES CITY �/l/�l � ENVIRONMENTAL HEALTH DIVISION W EVOPERATOR �' BIL=PARTY Y DBA S/I"✓�I"M)�S� L757ti c- PHONE #1 ADDRESS CC � / �` / r ' J v PHONE #2 (;� ) 4 7�' CITY STATE ZIP —APN # land Use Application # EBE�Dit Location Code CONTRACTOR and/or SERVICE REQUESTOR LILA � 7l t��l �`� BILLING PARTY // N DBA �iJ� ��s �� PHONE #1 ( ) (o S- ��¢�� MAILING ADDRESS `C) / US ��/�� l v K A :F)2 m ' -�— X # ( ,2e-) /) `�7� 53� CITY v N STATE C-4— ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/END 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 1 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 Feder A laws. 1 APPLICANT'S SIGNATURE Title: T/ �= Date: 7-5-2-7 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 dat environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon s it is available and at the some time it is provided to me or my representative. Nature of Service Request: III U` i Service Code , R X Employee # Date Assigned to �'"` Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By ACCT _/ / UNIT CLK _/ /