Laserfiche WebLink
USERVICE REQUEST oO�`- (EH 00 61) Revised 8/23/93 / <br /> lU / <br /> FACILITY ID # 007 RECORD ID # INVOICE # p � / <br /> FACILITY NAME /A/7(/U C !CL r _ s �� =�✓U �w BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY S V c. CA ZIP <br /> V / C' I (1 <br /> OWNER/OPERATOR �lO � L7 l/0 BILLING PARTY Y / N <br /> DBA /J1 a��,i/l c'^-'� _ PHONE.#1 (�7 )_�'/� - �/� !Lj <br /> ADDRESS 1 �` 1. U��P/L�� �]n- PHONE #2 C l I )✓ 1_L '�. <br /> CITY 1 (/\�C�'-' STATE ZIP y / IOZI <br /> p APN # P Land Use Application # <br /> I I .1 Bos Dist Location Code <br /> ' CONTRACTOR and/or /y <br /> SERVICE REOUESTOR ��� / / SS6C. i �e BILLING PAR <br /> �/(1TY Y / N771 <br /> DBA <br /> _�y^���y.� v / PHONE #1 ( I(G ) �- <br /> "MAILING ADDRESS /` \�"��A- //q' " "� e "' FA%-#_ <br /> CITY / \0416 .6 v-�l7"/GL�1,`-I'.STATE Clq ZIP <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 associatedwith 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 /> APPLICANT'S SIGNATURE '. _ <br /> Title- Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 ENVIRON TAb,IIEALT ,DIVISION as soon as <br /> it is available and at the same time it is provided to me or nr/ representative. _ <br /> Nature of Service Request: Iv lam. TDate <br /> Cpo�de Q� J <br /> Assigned [ 1 i HI// n I/ C 3� lti-� Employee N ,LJ� L/ /Date Seryice-Completed / / .Further Action Required: / LEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check-# R41 ecvd ey <br /> }jJ1144 7/1 /-------------------- <br /> 1i <br /> RENS /L0/ / ✓ SUPV _/ / ACCT IlJ/ /U't�LUNIT CLK <br /> O w 1 <br />