COMPLIANCE INFO_1994-1999 - Laserfiche WebLink

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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # i_A; INVOICE # 9a 3 11 V FACILITY NAME J,�/UIQ/ ✓✓ �4G�l.��>J` BILLING PARTY Y / N SITE ADDRESS CITY P0111 CA ZIP b 7 NER/OPERATOR BILLING PARTY Y / N DBA llyJ�/�i�✓ PHONE #1 ADDRESS ///7 / /�///�GL� d/ � PHONE #2 ( ) CITY �! YO) STATE /'f/� ZIP �z C C� FAPN # Land Use Application # S /� /` .�`� A-}04C �'c1l/(`�I%%7`/1 BOS Dist Location Code CONTRACTOR and/or /q SERVICE REQUESTOR BILLING PARTY Y N DBA PHONE #1 ) �- MAILING ADDRESS / �-D � 5 � FAX # CITYt�{� 5f �2 STATE � ZIP 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 1 have prepared thi application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and St ards State and deral laws. ' APPLICANT'S SIGNATURE Date: X Title: (�! -- � � `�1 J UiiV PUBLIC HEALTrl SCRI i AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the o"/'1RC@ifilWT%k1[prp of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and'�oP� environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SQ1 CES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: - Service Code (� Assigned to Q--C: _taw^Employee # Is7 Date Date Service Completed / / Vurther Action Required: Y / N PROGRAM ELEMENT D Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/ / SUPV _/ /' ACCT J /� / DoZ /%S UNIT CLK _/ /