Laserfiche WebLink
2-19-1998 10:3AAM FRO0 � p_2 <br />e SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br />FACILITY ID # 3 oo 1 <br />RECORD ID # FOT4 <br />INVOICE # (' s.� yZ <br />FACILITY NAME N c( SCA G" t to m PG r w N o» BILLING PARTY Y / N <br />SITE ADDRESS 3 --1�00 I/i) a P S' U(� Ci CL C <br />CITY ��"Ut-K4-0 � CA ZIP 7�vZCiS <br />OWNER/OPERATOR M tA�kCA Q 0/0 ryl P U f!i T BILLING PARTY <br />DBA _ K� W&k U i ( `' L( d^� `(� a PHONE 51 (5 C• ) 8 s ��H(� i <br />ADDRESS 3 L'I q (Cs.Jt r1 ba LiC�C f �CL(�l PHONE 92 ( ) <br />CITY 1-t b r n STATE O CA ZIP <br />;APN N Land Use Application I <br />u3 --- t S o IF <br />CONTRACTOR and/or <br />SERV 1 CE REQUESTOR taiy <br />DBA <br />q SL, Da <br />11 BOS Dist Location Code <br />BILLING PARTY Y =ON <br />PHONE #1 ( -ID 9_)y l p L- 3 5 1 <br />NAILING ADDRESS O5 -3!S7 FAX 0 (,:�9 )QLfi _ ir3L-(Q <br />CITY"Gly STATE 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 associated with 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 accord�SAN <br />JOAQUIN COUNTY Ordinance Codes and Stards, Si a ederal laws.( <br />APPLICANT'S SIGNATURE : <br />Ee ,� <br />v/ (c3©� �NVIRDj j y ij(ilM ry <br />Title: 1 i SC D Y1 Q (i Date: lypq�Ty IyTy <br />MFgL>7y���Es <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when app(icable, I, the owner, operator or agent of Sammy/( <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 eveilable end at the saw time it is provided to me or my representative. <br />Nature of Service Request: %!D%j L-ll)a-'a-4�—' ._ I Service Code IV T1 <br />Assigned to Employee # �/�D U Datef �3 , <br />Date Service Completed ,� / Further Action Required: H J / N PROGRAM ELEMENT23_ <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />,?,3`f -O—' <br />�`f ° ° <br />a/aq/q � <br />✓ <br />-A /t r t� <br />REHs I i/ / I SUPV I /�� I ACCT I /.J MW I UNIT CLK I �� <br />