Laserfiche WebLink
SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # �V INVOICE # <br /> FACILITY NAME ESTATE OF HICKINBOTHAM, ET-AL. BILLING PARTY r / <br /> 816 E. HAZELTON <br /> SITE ADDRESS 41D /✓y®f G 2/ JJf <br /> CITY STOCKTON, CALIFORNIA — CA zIP 95202 INv 7y <br /> AGENT FOR <br /> OWNER/OPERATOR ESTATE OF HICKI NROTHI, FT.Ai .ren BILLING PARTY / N <br /> DBA ATTORNEY DONALD U. BOSCOE PHONE #1 ( ) <br /> ADDRESS 45 HUNTER SQUARE PLAZA PHONE #2 �09 , 465 5628 <br /> STOCKTON <br /> CITY _ STATE CA ZIP 95202 <br /> F <br /> APN # p Land Use Application <br /> # <br /> FI I EEL <br /> OS Dist Location Code <br /> CONTRACTOR and/or JAMES HOBLITZELL (CONTRACTOR) <br /> RFRVNPF RFOWFSTOR _.�._.._.._._._.. .. BILk1NG PARTY Y 01 N <br /> DBA PHONE #1 ( U ) 94J-//93 <br /> MAILING ADDRESS Box 30331 FAX # ( ) <br /> CITY STOrKTON STATE C— ZIP 91521-3 <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN ' SIGNATURE COUNTY Ordinance Codes Standards, S to a� edera aws. <br /> APPLICANT <br /> Title: AGENVATTORNEY FOR ESTATE Date: 31 OCTOBER, 1994 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator 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 <br /> Is provided to me or my representative. <br /> Nature of Service Request: 4 Service Code 0� y <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amaxrt Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _/ / ACCT �f/_Gu UNIT CLK / /— <br /> Pa�E I <br />