REMOVAL_1994 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST AJ?LLJ (SERVRFQ) Revised 8/23/93 IFACIL I TY ID M 1 1 RECORD IO g 1 ' INVOICE 0 I'AGILITY MAMA ,l�U/T;.��/77J%i'A i /'/�.-&Pn�,) nn'' BILLING PARTY Y / N SITE ADDRESS 5C16 1 1 �Vli YyI F�AJ R -0 - CITY 'JeA/ ©l zip q5-3, 7Li MMFR/OPERATOR DBA ADDRESS BILLING PARTY Y / N PHONE M1 ( ) PHONE N2 ( ) CITY STATE ZIP APR 0F Lard Use Appllcatlon K — Bos Dint Location code CONTRACTOR and/or rJ ,/� ,,,� I / SFRVICE REOUESTOR fA i E1J L)1 IW IL YVI C°-VI`KCl T i�IG BILLING PARTY (lS' -/S N DBA PHONE N1 (—CVC, MAILING ADDRESS Z& ��,/�(..1�(,L% (',i}N L7 �Yl ). �1/"�t% L') FAK / L ( ) CII4A-&) J-A-YL,10tj STATE (-%/A'-% 21P BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/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 I 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 Federal laws. APPLICANT'S SIGNATURE : Title: Det AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envlrormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as moon as It Is available and at the same time It In provided to me or my representative. II Nature of service R1eoluest(:� � r� ✓Ch .A.Y; c Service code Assigned to I I S.41 ow G-� U Employee N i� % �" Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt M Check 0 Recvd By SUPV / / ACCT / / UNIT CLK / /