Laserfiche WebLink
SERVICE REQUEST (EH 00 61) Revised 8/23/43 <br /> FACILITY ID # RECORD ID # r 3 , 17c INVOICE # <br /> FACILITY NAME ���2 CP(1�GICCLS ` Y �C�}N7 BILLING PARTY Y / N� <br /> SITE ADDRESS <br /> CITY CA ZIP �S <br /> ER/OPERATOR REGK�I-S D5,j�(�0��� T EBILLING PARTY Y / N <br /> V�n2 , r� 823 - 3 I Z I <br /> PHONE #1 (�) <br /> ADDRESS �` 1� / C PHONE #2 ( ZOCI ) 12, <br /> CITY Y \ STATE ZIP <br /> APN # Land Use Application # <br /> IF BGS Dist Location Code <br /> BILLING PARTY �/ N <br /> PHONE #1 (Z0=! <br /> W I��l� N� I�� FAX # ( 20J )�- l�cc�7i� <br /> MAILING ADDRESS <br /> CITY � K 1 STATE (2-r\r ZIP l 2 ,C� <br /> 209-9q8-)3K <br /> E, MY1zj L_L S-T, STt:fAe-Tax)� C 4 y�2(7S �W-SYS�t�21=��� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific alp} <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 accordagr �ti Nh�S�N <br /> JOAQUIN COUNTY Ordinance Codes tandard , tate and F at l s. <br /> APPLICANT'S SIGNATURE <br /> SEP 2 9 1997 <br /> 1 SAN JOAOUIN COUNT! <br /> Z-!�—Zq Title: • Date: PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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�t�oJme or my representative. / <br /> Nature of Service Request: 0 1� W& J, /, C 4.(-,LL Service Code <br /> Assigned to V Employee # �6 2 Date C/ / 2) 6 / 9 7 <br /> Date Service Completed / / Further Action Required: / N PROGRAM ELEMENT / C <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> x 3 cr m 3 y <br /> RENS SUPV _/ / ACCT _/ / UNIT CLK <br /> I <br />