Laserfiche WebLink
SERVICE REQUEST (SERVREQ) Revised 8/23/43 <br /> FACILITY ID B RECORD TD Alj( INVOICE IR <br /> A ✓✓✓ 111 <br /> rACILITY NAMEtlr. + � 91LLIN0 PARTY / N <br /> SITE ADDRESS IPA <br /> CITY c�-�T�UG •`�� CA ZIP <br /> nwwrk rtrwo ] C - BILLING PARTY log/ N t, <br /> DBA PHONE *1 <br /> ADDRESS PHONE N2 ( ) <br /> CITY STATE ZIP <br /> -ArN 0 —Land Use Application N <br /> =8OSDlst Location Code <br /> rF}NTkACld2 rxi/or <br /> .E RFOLiESTORcFC � ' ' BILLING PARTY Y / N <br /> D8A PHONE Al <br /> HAILINr ADDRESS SSU FAX 0 (,?()'1 ) <br /> CITY STATE ZIP <br /> ``- BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ail site And/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be bitted to the party Identified as the BILLING PARTY on <br /> Pagp 1 of this form. <br /> I also certify that I hUpprerethiLoppLication and that the work to be performed will be done In accordance with ell SAN <br /> JOAouIN COiiNTY Ordinancte And Federal laws. AY N <br /> APPLICANT'S SIGNATURE I `` <br /> f o OCT 51995 <br /> Title: Date- <br /> SAN <br /> Date: <br /> —�� SAN JOAQUIN C;OUNI-Y <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner,.eMrvtgr�Or, '*Wt-W `'$Wm, 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. <br /> Nature of Service Request: Service code <br /> AiSlgned to -41oyee M J Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT T- <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt * Check 0 Recvd By <br /> N. <br /> q % <br /> R€HS f / SUP �/ / ACCT �/� UNIT CLK _/ / <br />