COMPLIANCE INFO_1995-1999 - Laserfiche WebLink

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SERVICE REGUEST (EM 00 613 Revised $/23!93 jL FACILITY 10 S RECMD ID # INVOICE 0 FACILITY \�.�L 1 i �� * -� _� BILLING PARTT T / SITE AMAM Cl TT L i,.'�� CA ZIP 9� V QWWWOPERATOR LT-t_�\ ��,L-� .0 BILLING PARTY T / N i.. OSA PHONE #1 (n)0)a j� S ADDRESS Y •O. PHONE 112 c ) CITY �Mhr�lL'�'�i-r Z _ STATE � zip SAS 3 APN 0 W, Lind Us Application N7 "'tea+® ��e amm • e0s Dist Location Code CONTRACTOR WW— — SERVICE RE4UMOR f):Z2S —i\ SY 5"�'Y—rt�5 s ZI�� - L -- - I BILLING PARTY / N D � PI NE 1F4 ( 40A, I -94L4 j @%ILING ADDRESS ®3tp N.,. _ J yee i at « S STATE ` ZIP g 2 1 1 BILLING GMNT: I, the urAomigned owner, opomtor or agent of same, W-VMiOdP that Ott site and/or Project specific MISABD hourty charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY .on page 1 of this form. I atm certify that t have prepared this application and that the work to be performed witt be donne in accordance with all SAN 'JOWIN CMXTY Ordinance Codes and Standards, State and Federal lanae. APPLICANT'S SIWTURE Titte: ��C"L� \ O LC �Q1.�[X;=,6 Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appticabte, i, the owner, operator or agent of same, of' the Property located at the Wxive site addms hereby authorize the release of arry and ett resutts, ieotechnicat data and/or environmental/site assessment information to SAN JOAOJIN COUNTY PUBLIC !HEALTH SERVICES ENVIRONWNTAL HEALTH DIVISION as soon as it is avaitable acid at the in time it is provided to me or my representative. Nature of Service t: Service Code Assigned to Emptoym NY Date Date Service Completed /e_/ Further Action Required: T / N FmomELDONT c�v� Fee Amount Amotma Paid Date of Payment Payment Type Receipt S Check ! Roovd By RENS _J / SUPV ®_J®/ ACCT ��_____/. UNIT