Laserfiche WebLink
y �t`�x 3 ^•�" ,.. yk <br /> RAN <br /> 71 # } <br /> E REQUEST <br /> -EEH 00 61) Revised 8/23/93 <br /> ' FACILITY ID # RECORD ID #W <br /> _3 5 ' �' a <br /> r ,,,,. <br /> i' FACTLITY NAME �JVI/ B[LLIN PARTY a Y.- / } <br /> x SITE ADDRESS <br /> CITY <br /> • � G 2IP <br /> OWNER/OPERATOR , 6 BILLING PARTY Y <br /> iL PHONE #1 ( � ) IOC <br /> _F <br /> . ADDRESS J 8�V. 6 At, G I-D CS t-14 4 :: PHONE #2 ( I w <br /> CITY <br /> �1�f41N STATE <br /> APR # Lend Use.Application # <br /> SOS Dist Location Code � � <br /> � x <br /> 4 � <br /> CONTRACTOR and/or-..A.: �+ <br /> SERVICE REQUESTOR v <br /> BILLING PARTY N <br /> i+ <br /> DBA T PH 1 <br /> ONE # 0 <br /> -��� .. .. FAX # / <br /> NAILING ADDl�SS <br /> 7CITY= ZIPS IVL` <br /> BILLINQ ACKNOWLEDGEMENT: 1, the undersigned er, r for or agen of same, acknowledge that all site and/or project specific <br /> •r> PNS/EHD hourly charges associated with this ac li r activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form �a �� <br /> ak m� •' a� a "� r <br /> 1 also certify that I'have prepared this applica and that the work to be performed will be done in accort�th all SAN <br /> JOADUIN COUNTY Ordinance C s and St rds Stat nd Federal laws. ' as; .r <br /> k . <br /> Y k <br /> J A I'� 1 <br /> A+ APPLICANT'S SIGNATURE MA <br /> Title: <br /> J I Date. r: <br /> .FA TI r`I1`11 C.E4 he. <br /> AUTHORIZATION.T0 RELEASE INFORNtAtION: a ition to the above, when applicable, I, the owner, operator or agent of same, of ,. <br /> the property located at the abov' it dd ess hereby authorize the release of any and all results, geotechnical data and/or <br /> "environmental/site assessment fo on to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROU14ENTAL HEALTH DIVISION as soon as <br /> it is available and at the s time i s provided to me or my representative. ` <br /> Nature•:of'Service Request: ��y Service Code <br /> �� i •iii _ 'r-. .. ,, .... . .. <br /> Assigned to P Employee t! L� Date <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 /> V29 <br /> RENS / t✓ SUP% _/ / ACCT / / UNIT CLK _/ ! <br />