REMOVAL_8_31_94 - Laserfiche WebLink

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SERVICE REQUEST r„s�(,!,`._ gE!,VRF70) Revised 8123/43 FACILITY ID g RECORD ID 0 I INVOTC^ g r a -jl ^rft rACILITY NAME ` ` t h I_17Av FYILLINQ PARTY Y / N SITE ADDRESS5660 //sa . A(RPop- CITY S oC 4 N CA ZIP "FR/OPERATOR U 3,� p4 O F I J2n.vspa?-iA bcQN BILLING PARTY DBA _ PHONE M1 ( ) ADDRESS 1(5 .7.5 ile /ACL PHONE M2 ( ) CITY Check a STATE C/F �7 21P 7 s—&)' --APN a 1U Land Use Application R ROS Dist Location Code CONTRACTOR and/or SFRVICE REOUESTOR A20A)S0(1) _ Y / N DRA PHONE M1 ( 7/G ) '- p i' 1600) MAILING ADDRESS �� v 9 .(de cy-1w2 S / /• FAX (0 (i-"-)3 6 1 CITY , (r' / STATE C ZIP TILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PIIS/EHD 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. I also certify that 1 have prepared this a tion and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY ordinance Codas, and Sifandards\Statl0i and Federal laws. APPLICANT'S SIGNATURE -r- 14 k-� title: e-"e-LIIYFA Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 envirormental/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 my representative. Nature of Service Request: J -0S u.f'� F�.�' I Service Code Assigned to GC�%��n 02 /``-eL—&(fFEnployee M Um, 4 Date service Completed _/—/ Further Action Required: Y / N Date PROGRAM ELEMENT -�2 3 Fee Arrant Amount Paid 7D;ateofayment Payment Type Revel pt N Check a Recvd By 023 X234 ob 1U RFNS �.—. I _// nIDY _/_/_ ACCT J/. —Cv i