Laserfiche WebLink
a <br /> SERVICE REQUEST (}� (EH 00 61) Revised 8/23/93 <br /> EL <br /> ITY 1D # RECORD ID # I ( tom( J INVOICE # -M6-1 <br /> =�-1 <br /> FACILITY NAME , el J �i BILLING PARTY Y / N <br /> SITE ADDRESS ` <br /> CITY CA ZIP <br /> � r <br /> S , <br /> OWNER/OPERATOR BILLING'PARTY Y / N <br /> DBA PHONE#1 ) _ <br /> ADDRESS PH ( ) T <br /> CITY b�� STATE CIA — ZIP <br /> APN # Land Use Appl i cati.on # <br /> BO IF /f7k TDist Location Code <br /> CONTRACTOR and/or V�� C-5—a E <br /> SERVICE REQUESTOR BILLING PARTY !� � �'/ N <br /> DBA - PHONE #1 <br /> l�`� •z�V. ( ) <br /> MAILING ADDRESS + FAX # <br /> 9�l r� (� <br /> CITY ,�VVI,�"��/�� STIf7E ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the u rsigne o er, op for or agent of same, ackno ledge that all site and/or project specific <br /> PNS/EHD hourly charges asso ed with th' facility or activity will be billed th -party identified as th BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared his application and that the work <br /> wworrkk ,,to be performed wil be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes an Standards, State an F. deral laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE NFORMATION: In addition to the above, when applicable, 1, the owner, oper for or agent of same, of <br /> the property located at he above site address hereby authorize the release of any and all results, eotechnical data and/or <br /> environmental/site ass ssment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL EALTH DIVISION as soon as <br /> it is available and a the same time it is provided to me or my representative. <br /> Nature of Service Request: � <br /> Service ode _ 1 <br /> Assigned to \u�C6�V► ' Employee # coo 1 Date G/ -7' <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -7 601 <br /> /--T SUPV / / ACCTi/ /l I / �' UNIT CLK _/ /' <br />