Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # / RECORD !D # INVOICE # <br /> FACILITY NAME SUE 1:lNJDLy DNL EAJD0C� BILLING PARTY Y / <br /> SITE ADDRESS :Z///?�i'�/J� <br /> CITY _Vl///lSC) 1�v1 _ CA ZIP <br /> OWNER/OPERATOR -5)A M K BILLING PARTY Y / <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> —APN # and Use Application # <br /> BOS CLO <br /> Code <br /> CONIRACTOR and/or /�� _ <br /> SERVICE REOUESTOR BILLING PARTY <br /> DBA PHONE #1 <br /> MAILING ADDRESS (,-) FAX <br /> CITY <br /> # ( ) <br /> CITY STATE ZIP %5-31- L <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all sitepor project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifiePARTY on <br /> cl�Q �� t�jl�, <br /> Page 1 of this form. Itt99// <br /> I also certify that I have prepared this application and that the work to be performed will be done�PTGpr/!)ar _w;th all SAN <br /> JOAQUIN COUNTY Ordinance Codes a tandards, S e and Federal laws. SqN <br /> FN�iR��Ll H 2141 j�COIJA <br /> APPLICANT'S SIGNATURE <br /> FS <br /> /) p"SlOA <br /> Date• <br /> Title: <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 /> Service Code l � <br /> Nature of Service <br /> nRequest:�` (r <br /> "1�1�i -� (;j b! 1�C1S2�J�� Employee # 7- �/ ? G / 7 <br /> Assigned to Date�'/�'� <br /> �l 7 Y /C PROGRAM ELEMENT <br /> - Further Action Required: �C3 <br /> Date Service Completed / 1 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> [REHjS /�_/� SUP _/ / ACCT �/ / UNIT CLK]��—�—j <br />