Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # lA INVOICE # - <br /> FACILITY NAME Pie� N S k E TR u.ce Leasi .# 9 BILLING PARTY Y / N <br /> SITE ADDRESS ( .) C.� [I� / '�-t�✓L�z ��! -n P <br /> J <br /> CITY Sf(� C, I\ T(TY(� CA ZIP -( - S <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> p APN # F and Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or /1M CA D <br /> SERVICE REQUESTOR /-li ll BILLING PARTY Y / Nr <br /> DBA PHONE #1 ( 6 /J ) 73 ,Y A' <br /> MAILING ADDRESS // /p�l L-• � 5-M 29 L^-C_ x/103 FAX # <br /> IC ( ) - <br /> CITY � �I C-C_ STATE � ZIP -/ rJ <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 COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> PAYMENT <br /> APPLICANT'S SIGNATURE F;Fc <br /> 'E.111ort <br /> Title: Date: JUL 2 7 1995 <br /> SAN JOAQUIIv - Uy; <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, opaVq&C4gEA�`Y}� P Vof <br /> the property located at the above site address hereby authorize the release of any and all rei)QJf$RCR9 tp -l,v,.,,,.,. <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. 7 <br /> Nature of Service Request: lilL11 /' �/� J Service Code 1 <br /> Assigned to �/ Employee # � (,//(.jO /^\ Date --7-/��/ <br /> Date Service Completed / / Further Action Required: , 1 N PROGRAM ELEMENT 3 e / S <br /> Fee Amount Amount Paid Date of Payment Payment Type SCC///Receipt # Check # Recvd By <br /> Oa`f Gd / oma � �� k- `�J� C` l1K (On 7 <br /> RENS / / J SUPV / / ACCT _/ /_ UNIT CLK _/ /_ <br />