REMOVAL_1998 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # ` RECORD ICI # INVOICE # FACILITY NAME Ll)c)_v_�, b� ��)w.II ) - (�.. BILLING PARTY Y / / SITE ADDRESS .2 / CITYCD— CA ZIP ER PERATOR J 1 C� L/v r J �f J BILLING PARTTYY 2/ N 3 DBA PHONE #1 (//b ) 3L/ 7S- ADDRESS �!1 Oi / G / PHONE 92 CITY Cf tiSiV2 STATE S� ZIP 60< i avH it I�Land Use Application # 805 Dist I Location Code I. I CONTRACTOR and/or / /I r��F SERVICE REOUESTOR �/) L / BILLING PARTY Y� / N DBA PHONE #1 MAILING ADDRESS /)0�0 /Z L:S FAX # ( ) CITYC�//�C i�� STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/FHD hourly charges associated with this facility or activity will be bilLed to the party identified as the BILLING PARTY on Pagel of this fora. - I also certify that i have prepared this lication and that the work to be performed will be done. in accordance.uith all SAN JOAQUIN COUNTY Ordinance Codes and St rdsStata L Federal laws. _ APPLICANT'S SIGNATURE o^ Title: 0 `5I �yy , Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or emirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or Py representative. Nature of Service Request: Service Code Assigned to Enployee # Date Date Service Completed _f / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/_�_ Sl1PV _/_/_ ACCT J_/_ UNIT CT _/_f_