Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> 'y^^, FACILITY ID # <br /> RECORD ID/# alo INVOICE # <br /> "\ FACILITY NAME C�'� 4(; -/if�J1_0pG`K//c^�� C G BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CA ZIP /`J'�" 5 <br /> /\OWNER/OPERATOR �C�r��L��/h 1/�Y '-'�/f�J� BILLING PARTY Y / /N <br /> (( DBAGG�.�"G � � �4/ PHONE #1 <br /> ✓ ADDRESS /f / q/ �PHONE ##2woe <br /> ( ) <br /> CI T.1f�J /G��/� /IJA / STATE M ZIP <br /> FA—ApN # Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR 6 BILLING PARTY <br /> DRA PHONE #1 ( ) <br /> MAILING ADDRESS 7 FAX # ( ) <br /> CITY S �/ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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. -11 <br /> 1 also certify that 1 have prepared this pplication and that the work to be performed will be done in�a�`c1cogrdance yy ith all SAN <br /> �l! JOAQUIN COUNTY Ordi nonce C s St <br /> a r , State and Federal laws. IrOy 1 Z' � "�'i <br /> \ APPLICANT'S SIGNATURE BLI <br /> ( ��� j/ / , PUNME <br /> Title: Dale: <br /> NEAL HEALTH olvisiUN <br /> (�/- <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 /> environmic l/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 /> s <br /> Nature of Service Request: �� '(d. �'� Service Code <br /> Assigned to fll��f Employee # `� Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 4r CSV <br /> Fee Amount Amount Paid ate of Payment a Receipt # Check # III By <br /> 71 <br /> REHS / G^ / SUP V _% / ACCT /_/ UNIT CLK / /_ <br />