COMPLIANCE INFO_1997-2006 - Laserfiche WebLink

Home Browse Search

-- _ _ ....w_....w. G-LC7"-I:9�Jt3 1 I :T10EN1% P`FtUivi_. __ ___ .. .___� SERVICE REQUEST (SERVRBo) Revised 11/02/93 FACILITY ID 0 ® RECORD ID ax j�V1 INVOICE 0 FACILITY NAME �a +� y BILLING PARTY Y / N SITE ADDRESS " • r RECEIVED CITY Sf C-,L / A� CA ZIP 06-5 FEB 2 7 1995 OWER/OPERATOR 1 �• BILLING T�yr� NMLL DBA C 4` . PHONE 01 C ) ADDRESS 19,0 >��k L2 a/ PHONE a ( ) CITY Q11 �[?�111D/'1 STATE ZIP APN 0 Census -----�HBITS Dist Location Code city Code - -- CONTRACTOR and/or / //�� SERVICE REQUESTOR C�ILl�dfTPARTY DBA // �YJ��C/.f Ott ( �j�'I_� /�U f_ / G,D`f PHONE 91 ( ) -yL NAILING ADDRESS /) e V j F--rP /h eel '- --- FAX ( ) CITY J �CL� _ STATE ZIP BILLING ACKN0YLEDGa4FNTI I, the undersigned owner, operator or agent of same, acknowledge that all site ardor project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page i of this form. I also certify chat I have prepared this application and that the work to be performed will be done in accordance with alt SAN JOAQUIN COUNTY OrdinancZC*des and St , ate and rat Laws. APPLICANT'S SIGNATUREJr Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when dppllcable, 1, the owner, operator or agent of same, of the property located at the above Site address hereby authorize the release of any aM all results, geotechnical data &fWlor environmental/site assessment information to SAN JGMIN COUNTY PUBLIC HEATH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon Mrs it is available and at the same time it is provided to me Or sM repreelsftative_ q sc—& c Nature of Service Request: #. Service Coda _ evployee 0 4 iI /J Date ��_.LLZ Assigned to ' E7rsY Date Service Completed _/ J Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payn mt Type Receipt 0 Check 0 Recvd By ca REHS ACCT UNIT CLK