Laserfiche WebLink
2r3z<* <br />SERVICE REQUEST <br />/1-11-1 6300 <br />-j�v ­(SERVREQ) lised 8/23/93 <br />,FACILITY ID # <br />tmount Paid <br />t10 <br />INVOICE # <br />Receipt # Check # Recvd B <br />FACILITY NAME <br />SITE ADDRESS � � c/ /V Au/ / <br />CITY _ CA ZIP � 27W <br />BILLING PARTY Y / N <br />r- <br />OWNER/OPERATOR Cvy" ®`2 BILLING PARTY / I� <br />DBA ` 1 PHONE #1 <br />ADDRESS "� I / 1®i% A-10 4 -MOA -1 PHONE #2 ( ) <br />CITY —/ � •� �" ' "' STATE L o _ ZIP <br />F APN # Land Use Application # <br />:IF r'BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR - `'wed BILLING PARTY / N <br />DBA 1 \// >°�S�C I "[ � PHONE #1 (—V7) ��-�p <br />MAILING ADDRESS / AM 8 <br />CITY /_`f_ <br />VV -1 I �JI LLe 1� �FAX # ( ) - <br />�j <br />STATE ZIP , f / 5—z — r t/(7, <br />BILLING ACKNOWLEDGEMENT: I, 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 accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br />APPLICANT'S SIGNATURE : <br />Title: <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <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 available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to �� � / 1y11CA/1'V Employee # <br />Date Service Completed / / Further Action Required:/ Y, / N <br />Service Code <br />Date / / <br />PROGRAM ELEMENT 2 3' & 0 <br />Fee Amount <br />tmount Paid <br />Date of Payment <br />Pavmt Type <br />Receipt # Check # Recvd B <br />77 <br />12,S77 ^1117 <br />-TzVU. <br />RENS _/ / SUPV _/ / ACCT /-d /� 3 UNIT CLK _/_f <br />