Laserfiche WebLink
lb SERVICE REQUEST • (SERVREO) Revised 8/23/93 <br />FACILITY ID # RECORD ID # q INVOICE # 1130 -7 o <br />FACILITY NAME Co -",V\ BILLING PARTY <br />SITE ADDRESS —\Zj <br />CITY CA Z I P - <br />17N <br />PW1JFR/OPFRATORBILLING PARTY QJT--� N <br />I ---- I <br />DBA PHONE #1 <br />ADDRESSZZ PHONE #2 <br />CITY STATE L/ ZIP C19 <br />APN Land Use Appt icot ior <br />BOS Dist Location Code <br />CONIRACTOR arid/or <br />SERVICF REQUESTOR <br />DBA <br />BILLING PARTY J Y / rDN <br />PHONE *1 445-6 <br />!'AILING ADDRESS 16&b * /ff-/SZI FAX k <br />CITY 1%.,Cd1' STATE C/1 ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/END hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br />Page I of this form. <br />I also certify that I have prepared this application and that the work to be performed wit[ be done in pJ�MAJh all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standar s, State d Federal laws_ <br />APPLICANT'S SIGNATURE I I I K1 -1 9 Inno <br />T i t t e: C, Date. 604 A & S A N , u A 0 U (,,, l, i,l �N i�' y <br />r r-UbL1UCAH EALTH SERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when srrticnbLe, 1, the owner, opera o <br />the property located at the above site address hereby authorize the release of any and ail results, geotechnical data arid/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES LwNVFRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me- or my representative_ <br />Natureof Service Request:Lice Code !� - <br />Assigned to -T') 944)-r�� Employee Date �I <br />Date Service Completed Further Artion Required: Y / N PROGRAM ELEMENT 2 yoz <br />Fee Amount <br />Amount Paid <br />Datf? of <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS <br />SUPV <br />aL <br />UNIT CLX <br />-C <br />REHS <br />SUPV <br />Ar' T <br />UNIT CLX <br />