COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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OWNER/OPERATOR , i'�cr�, �_nnar�rJ.lx f r SoC k �oyt�s/C BILLING PARTY Y DBA -� ' �- PHONE #1 ( 09 ) 9f3 S33 1 ADDRESS a®O V S4","-!FoA RGc`G( PHONE #2 ( 6101 )lk-3 - 5-,l 0 0 -- CITY _ S� e h+� STAIE _4C)9 _ ZIP 9!-!!;W 6 — APN # — Land Use Application # BOS Dist Location Code CONTRACTOR aril/or SERVICE REOUESTOR 41111'OnCt �n✓irar+m�n';��1 Sc'r✓/'teS BILLING PARTY PHONE #1 (530 )JVS - 9.56 2 DDA L MAILING ADDRESS ®�Q °Thorn T/"Cef de.�rlac d 6 - FAX # (Sy s 3 )3y- )"'C-* CITY CA,'e p STATE e�_ zip `%J-/ %-3 BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PIIS/END 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. R//E��iiC11EYY��IGG��'illn I also certify that 1 have prepared this application and that the work to be performed will be done DEC(� c�rc),angA all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. SAN JOAQUIN . H COUNTY APPLICANT'S SIGNATURE a��R�it N siTNALHDISERVICES ENVIRONMENTAL HEALTH DIVISION Dote: //-oZ6 `f;7 AUIIIORIZATION 10 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of smre, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirorwnental/site assessment information to SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the srwne time it is provided to me or my representative. I Service Code in Nature of Service Recpiest: I� ZQ a— Assigned toy ��1� Enployee # _ � % 3t Dote IDate Service Completed %_ _/___ Further Action Required: Y / N I PROGRAM ELEMENT SERVICE REQUEST (Ell 00 611 Revi 8/23/93 ID # RECORD ID # I t�® INVOICE # 74J = FACILITY' FACILITY NAMEW/ /I 44r le %kDGI'f/>7e n / i SfoCk�on i� f9SF __ BIL=PARTY Y / SITE ADDRESS S11'j"So.w K044 ' CITY ��4Y\ CA 2 I P_ q5 oZ OWNER/OPERATOR , i'�cr�, �_nnar�rJ.lx f r SoC k �oyt�s/C BILLING PARTY Y DBA -� ' �- PHONE #1 ( 09 ) 9f3 S33 1 ADDRESS a®O V S4","-!FoA RGc`G( PHONE #2 ( 6101 )lk-3 - 5-,l 0 0 -- CITY _ S� e h+� STAIE _4C)9 _ ZIP 9!-!!;W 6 — APN # — Land Use Application # BOS Dist Location Code CONTRACTOR aril/or SERVICE REOUESTOR 41111'OnCt �n✓irar+m�n';��1 Sc'r✓/'teS BILLING PARTY PHONE #1 (530 )JVS - 9.56 2 DDA L MAILING ADDRESS ®�Q °Thorn T/"Cef de.�rlac d 6 - FAX # (Sy s 3 )3y- )"'C-* CITY CA,'e p STATE e�_ zip `%J-/ %-3 BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PIIS/END 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. R//E��iiC11EYY��IGG��'illn I also certify that 1 have prepared this application and that the work to be performed will be done DEC(� c�rc),angA all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. SAN JOAQUIN . H COUNTY APPLICANT'S SIGNATURE a��R�it N siTNALHDISERVICES ENVIRONMENTAL HEALTH DIVISION Dote: //-oZ6 `f;7 AUIIIORIZATION 10 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of smre, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirorwnental/site assessment information to SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the srwne time it is provided to me or my representative. I Service Code in Nature of Service Recpiest: I� ZQ a— Assigned toy ��1� Enployee # _ � % 3t Dote IDate Service Completed %_ _/___ Further Action Required: Y / N I PROGRAM ELEMENT