COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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SERVICE REQUEST ``�� (SERVREQ) Revised 812 /93 J rACI1.ITY NAME f SITE ADDRESS � 0 10 CITY %� / C�iCa� CA 21P NER/OrFRATOR BILLING PARTY Y DBA a YL-�J- , 0 U PHONE N1 ADDRESS ,9 0 7.';� W Q 0S c � M / t e A V e - - -- PHONE 02 (—)-- CITY ri PC �� STATE �— zip — APN N� Land Use Application N F-ROS ist Location Code NTRACTOR nn d/or RVICE REQUESTOR Y [ 5 F' 1� (i ! Py �' ` l� V 11-0 /'h Hyl ��1 BILLING PARTY L / N DRA PHONE N1 (! U� )C / -/ 1LING ADDRESS ) FAX N (0�oy )�O U(> CITY L STATE _ zip�,� 2/z RII.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Pnge 1 of this form. I nlso certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, tat nd Federal eral laws. ArPLICANT'S SIGNATURE : Title: I ate. — 36 AUTHORIZATION to RELEASE 1000MATiON: In addition to the above, when applicable, 1, the owner, operator Iagent of same, of the property located at the above site address hereby authorize the release of any and all results, geote nlcal data and/or environmental/slte assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is nvailable and at the snme time it Is provided to me or my representative. Nature of Service Request: r iV S d Service Code Assigned to 'e'll & Employee N %`/ �-- Date / I Date Service Completed —1-4__ Further Action Required: Y / N PROGRAM ELEMENT ree Amount AmountPaid Date of Payment l , Receipt N Check N rACItITY ID N I RECORD IDN I, INVOICE --. — J rACI1.ITY NAME f SITE ADDRESS � 0 10 CITY %� / C�iCa� CA 21P NER/OrFRATOR BILLING PARTY Y DBA a YL-�J- , 0 U PHONE N1 ADDRESS ,9 0 7.';� W Q 0S c � M / t e A V e - - -- PHONE 02 (—)-- CITY ri PC �� STATE �— zip — APN N� Land Use Application N F-ROS ist Location Code NTRACTOR nn d/or RVICE REQUESTOR Y [ 5 F' 1� (i ! Py �' ` l� V 11-0 /'h Hyl ��1 BILLING PARTY L / N DRA PHONE N1 (! U� )C / -/ 1LING ADDRESS ) FAX N (0�oy )�O U(> CITY L STATE _ zip�,� 2/z RII.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Pnge 1 of this form. I nlso certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, tat nd Federal eral laws. ArPLICANT'S SIGNATURE : Title: I ate. — 36 AUTHORIZATION to RELEASE 1000MATiON: In addition to the above, when applicable, 1, the owner, operator Iagent of same, of the property located at the above site address hereby authorize the release of any and all results, geote nlcal data and/or environmental/slte assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is nvailable and at the snme time it Is provided to me or my representative. Nature of Service Request: r iV S d Service Code Assigned to 'e'll & Employee N %`/ �-- Date / I Date Service Completed —1-4__ Further Action Required: Y / N PROGRAM ELEMENT ree Amount AmountPaid Date of Payment Payment Type Receipt N Check N Recvd By Q'k 'OD L11 '� tt n REHS / / Sl1PV L ^/ / I ACCT _/�` 1 UNIT CLK I^/ !� I