Laserfiche WebLink
SERVICE REQUEST <br />0 CEH 00 61) Revised 8/23/93 <br />0 FACILITY ID # RECORD ID #//�L INVOICE # <br />FACILITY NAME VA ie- Ii l� ?/-V�UL- e!:�tH ` AL ��BILLING PARTY Y / <br />SITE ADDRESS <br />CITY 4712 y -"Y' ` 1W CA <br />TOR �7 ✓ l �G/Lt/✓ / r' 1�"t +1'� I �`t `/ BILLING PARTY <br />DBA C�l/ �i�'C� W G�6 T til�"� �VG % 1— PHONE #1 (1 I (O <br />RESS I -D' I `' lY OSI 0 PHONE #2 ( 6 )514 - <br />CITY Vim/ ,` I" STATE ZIP <br />Land Use Application # I- <br />BOS Dist Location Code <br />CONTRACTOR and or <br />SERVICE REQUESTOR <br />DBA�71� <br />MAILING ADDRESS <br />BILLING PARTY Y / N <br />PHONE #1 (-40+)165'1&6Q <br />FAX # ( )46 zi- 110L-5 <br />CITY f�5�fAVUH A STATE Ce:A ZIP 61+1 <br />P — <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 />1 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 C and St dards, State and Federal laws. PAY M E W <br />7J. , IT _ gpc.rI IIFn <br />APPLICANT'S SIGNATURE : <br />TitIe:011 I -y`l-�/ ►`t I Date: f/ <br />—' ppp SANJOAQUINCOUNTY <br />ES <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operatQ(UBt,II IV'H� i AL�Hv�UlVIiION <br />the property Located at the above site address hereby authorize the release of any and all results1,- geo ec niek c�a a eAd/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 <br />Request: Lit c�� �Le � � I Service Code U ti <br />Assigned to / � R1� !ti'! "` Employee # Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z Q <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />