COMPLIANCE INFO_1996-1999 - Laserfiche WebLink

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• .� SERVICE REQUEST Gi � (SERVREQ) Revised 5/13/93 FACILITY ID # RECORD ID # V 1 BILLING PARTY Y / FACILITY NAME SITE ADDRESS ��0 I/ ✓v� �GI 1►W► ' �/� 'C �iI/'►'`�VVV" CITY " W CA/ ZIP OWNER/OPERATOR { I�V� �"' � BILLING PARTY / Y ) / N DBA l �f l� �rO / W PHONE #1 (_)_- ADDRESS ) -ADDRESS l�1 F l�l/T /PD i tel PHONE #2 ( qll+ ) W70- 5-f23 CITY IW 1/►� I Al STATE _ ZIP g0OX 5' IO&p APN # Census BOS Dist Location Code City Code - --�- CONTRAC SERVICETRREEQUESTOR VIM --rff(Oa) BILLING PARTY -Y/ U DBA p�PHONE #1 (JI0 ) T116-_Q3 3 MAILING ADDRESS I 1 I pop FAX # ( Jif ) M5 '"I z(o CITY (Saa Wn ro STATE ZIP O`677 BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance wit4 all SAN JOAQUIN COUNTY Ordinance Code t�rc, tate and Federal laws. PAYM EN a RECEIVED APPLICANT'S SIGNATURE : If Title: ?m� ma�mvvl Date: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, opeiatWNbtEl*7§ft4nNF-Tibi;lSKfr'i the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code `Ct Assigned to kA) f es^- Employee # ti 3 Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By ell REHS /�/ SUP. _/ / ACCT _/ UNIT CLK _/ /