Laserfiche WebLink
v <br /> SERVICE REQUEST (EH 00 613 Revised 8/23/93 <br /> RECORD ID # INVOICE N <br /> FACILITY ID N 1 10 , <br /> F !!! <br /> FACILITY NAME G/,irde K tliTY JAI z"1•r��/1t.� BILLING PARTY Y / <br /> SITE ADDRESS ((a 4 7 O `/' <br /> CITY La}prop CA ZIP <br /> OWNER/OPERATOR IO�GD t�M arks+ln� ��• _ BILLING PARTY Y / <br /> DBA I(�i1 Q. K PHONE #1 ( oil& )�8- 1& 12- <br /> ADDRESS <br /> 2 <br /> ADDRESS 7l� 6roadwa�� ASL PHONE #2 ( 9iG ) SSB - 7L 14- <br /> CITY JaGfAiA/(eYL�o STATE GA zIP 1�78i� <br /> APN N FLand Use Application N — <br /> BOS Dist Location Code <br /> CONTRACTOR and/or iy10 Aaen� -F,y r T t(J SGD <br /> SERVICE REaUESTOB olga �7ian BILLING PARTY Y / N <br /> DBAWillow VPass 1A�OlIp (YYG. PHONE 01 ( `�)—Cej- <br /> yV /OV <br /> MAILING ADDRESS )6lq • / �Jl dd 420 FAX # ( -J10 ) �DOq - 304 <br /> CITY 6zmcord STATE GA ZIP 945Z0 <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 accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. PAYMENT <br /> RECEIVED' <br /> APPLICANT'S SIGNATURE Awe <br /> Title: <br /> AesrJt fon' oseo Date! �0/23/9� JUN 23 1997 <br /> SAN JOA <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicebl e, I, the o VVIR q ,FEit of same, of <br /> E�ll� "FEW <br /> 01t <br /> property located at the above site address hereby authorize the release of any and all res9i' N ati6zUAlNUIys81O1i, 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. <br /> Nature of Service Request: Service G��tn-G.�+�Y �V q Service Code 3 T <br /> Assigned to f) a:LkA W aEmployee N ( L �J Date (o /Z- C, <br /> (f ate Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 c) Y <br /> ' ee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3H T✓ <br /> ACCT <br />