Laserfiche WebLink
SERVICE REQUEST ! SR # <br />5/13/43 <br />FACILITY ID # <br />Amount Paid <br />RECORD ID # <br />i '�el ,#lLLIN Y / <br />FACILITY NAME <br />SITE ADDRESS <br />f3 G - Cow e 'AC # <br />. U # <br />CITY .5 /V C-14� /&-n- G ZIP 7S zD/v <br />OWNER/OPERATOR �� 5'fD Gie BILLING PARTY �7 Y / Cj <br />DBA PHONE #1 (�---0'� )7 - F11,F2- <br />APN # <br />ADDRESS Yg5 N• EG D,9R,4b6 PHONE #Z ( ) <br />CITY SADG'r74&71- STATE Ll14 ZIP 520 ?,- <br />I Census --------- SOS Dist I <br />Location Code City Code •..... <br />CONTRACTOR and/or <br />SERVICE REOUESTOR M"IF )CSTIG ��Gf/d�OCi/E_j ,L/�iL <br />DBA <br />BMLING PARTY / N <br />PHONE #1 ( '71zl'71 / S �� /.300 <br />MAILING ADDRESS .-� aZ 3 GS" EL /D%aD .el) FAX # ( ) <br />CITY L,/f,eE%OQI—S4 STATE �,%=T ZIP 0 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site arid/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 COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />Tit <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, 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: %Ne /P «4d'J'4 Z- Service Code _ <br />Assigned to �/ iti�Fl iJ E'/�/ Employee # Date <br />Date Service Completed _/ / Further Action Required: Y / N I PROGRAM ELEMENT .' 3 , 50 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS / / SUPV / / ACCT / / UNIT CLK / / <br />