Laserfiche WebLink
1. <br /> 5 c ���3� <br /> SERVICE REQUEST CEH 00 61) Revised 8/23/93 <br /> FACILITY 10 # RECORD ID # INVOICE # <br /> FACILITY NAME (7e- - N' 40 /'/CL 1-� BILLING PARTY <br /> SITE ADDRESS 5 747 <br /> CITY e--C- CA ZIP /S 3 7C <br /> OWNER/OPERATOR FBILLING PARTY _ _ / 1 <br /> 133 -ADBA C E�'� ^ ��'- C� PHONE #1 )_133 - <br /> ADDRESS <br /> DDRESS / 1 �'JTL/'��� • PHONE #2 <br /> CITY ��/rL°.S/ STATE 61 - ZIP <br /> APN # and Use Application # <br /> SOS Dist Location Code <br /> I I <br /> CONTRACTOR and/or L <br /> SERVICE REQUESTOR SXce h'O� T i�/Icc/76P. _L qL _ BILLING PARTY <br /> DBA �/f?Y� S 41A/�73W�XJCr-6U �iC1�- PHONE #1 C Z 0 )�(C - �y�� <br /> MAILING ADDRESS PC) 3cx M5-10 FAX # ( <br /> CITY %(/r /Of/� STATE C4- ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in qcf <br /> ,qFdanIl t�th all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State Federal laws. rR E CEIV E r. <br /> APPLICANT'S SIGNATURE �2' �'�/%� ' n P n 1 O 1997 <br /> Title:- c�� r (mac aeDater 2�/�l7 ,,1v L.;11 u <br /> �3Lic HF-; ; . <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner; op br 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 ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. ]C� p <br /> Nature of Service Request: ZEA U o< i - Service Code ! 1 �1 <br /> Assigned to1 Employee # Date j <br /> Date Service Completed �/ I� / ' Further Action Required: Y / PROGRAM ELEMENT 3 %� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 6(41 U <br /> .. 3 1�- 3 , <br /> REHS `F SUPV / / ACCT _/ /_ UNIT CLK <br />