Laserfiche WebLink
p <br /> SERVICE REQUEST <br /> (SERVREq) Revised 23/23/93 <br /> l FACILITY ID # <br /> JRECORD ID # INVOICE # <br /> B.T. RANCH VINEYARD rte/LLJJ O {� <br /> FACILITY NAMERATTTE <br /> BILLING PARTY Y / N <br /> SITE ADDRESS <br /> i <br /> CITY CA ZIP�RJ240 <br /> OWNER/OPERATOR SAME AS ABOVE BILLYNG PARTY Y / N <br /> A <br /> OBA <br /> PHONE #'1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE <br /> IIP <br /> APN # <br /> Land Use Application # <br /> 605 Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR (h TXC BILLING PARTY <br /> DBA PHONE #1 ( 909_)-4ZJ AD <br /> { <br /> MAILING ADDRESS 457A F .ATRER R-TVi+._R_ n$. � STr'LTE A,_ FAX # <br /> CITY TOCIfTON STATE r.A � ZIP 9ei21 <br /> BILLING ACKNOWLEDGEMENT: I the undersigned owner, operator oragent of same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party i WKTihe BILLING PARTY on <br /> Page 1 of this form. P F C F1VFFr) <br /> P <br /> 1 also certify that I have prepared this application and that the work to be performed will > " A Mlrba nce with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and standards, State and Federal laws. SAN J0.6,QU11v COUNTY <br /> f PUBLIC HEALTH SERVICES <br /> APPLICANT'S SIGNATURE J C- lll! ESV?PONMENTAL HE e <br /> Title: CIVIL ENUNERH 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 /> 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: SOIT, STTTTA1RT1,TTX RIFPORT Service Code <br /> K <br /> Assigned to ,_. _. r � E ogee # 6 `i' Date / <br /> � [ 7 <br /> Date Service Compteted /�JGZ_ Further Action Required: Y / PROGRAM ELEMENT ' <br /> i <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / / SUPV ��/ ACCT UNIT CLK <br />