Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID7# <br /> ��C�U/�7^ RECORD ID # � INVOICE # ✓' '�'J <br /> FACILITY NAME 7G C"- ,J [� Y�CIJ 7 �Q BILLING PARTY Y� / N <br /> SITE ADDRESS /T�pl7 / ,/r` L N-7� /rd t/n <br /> CITY CA ZIP J O <br /> OWNER/OPERATOR ///7.L W�y�/�.�f�f�//( �•fin� 1 BILLING PpARTY Y q / N <br /> DBA ©✓ ,l 6/' Y ,/v^ �r1 PHONE #1 (,F�' )�ra�'C.) <br /> ADDRESS _� nV �y/ ,� '^ 6° " 6 PHONE 02 (�)&- 627o <br /> CITY �./ 7-7 / rA& STATE _ ZIP / 20 <br /> APM # Lard Use Application # <br /> A BOB Dist Location Code <br /> OOR nd/or P � / <br /> SERVICERVICE REOUESTOR f� � N BILLING PARTY Y <br /> DBA /Vc' PHONE #1 (2 1 C <br /> MAILING ADDRESS "1 � l � // ` y + � ?FAX ( ) <br /> CITY (/� /�' STATE �[qq ZIP S i�l )10f t4P <br /> BILLING ACKNOWLEDGEMENT: I, 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. PAYMENT <br /> RECEIVED <br /> I also certify that 1 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. SEP 16 1997 <br /> APPLICANT'S SIGNATURE Af'w' cru JDA901H 00UNTY <br /> p //� PUBLIC MEALTM BEMOInCUE/S R \� S <br /> Title: / W ��` '-�" !7� <br /> Date: [ <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 /> envirorwrital/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 /> /— Service Code V <br /> Nature of Service Request: (� c] <br /> p� } <br /> Assigned to Employee 0 Date <br /> _ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 14-a <br /> RENS_/� rSUPV _/_/_ ACCT <br />