COMPLIANCE INFO_1997 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST {EH 00 61)//Revised 8/23/93 FACILITY ID # RECORD ID # �/ INVOICE r AGILITY NAME BILLING PARTY Y / N SITE ADDRESS c CA zip CITY a , OWNER/OPERATOR BILLING PARTY Y / fl DBA 1 I f PHONE #1paa-- ADDRESS -J �J a � PHONE #2 ( ) CITY � �/' STATEZIPtC FAPN # Land Use Application # IFBOS Dist Location Code ==J CONTRACTOR and/or ,. SERVICE REQUESTOR �I�? � + BILLING PARTY Qy) / N DBA 1 f PHONE #1 R It,:,) e MAILING ADDRESS FAX # ( ) CITY +��- �`r� STATE ' ZIP IP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Oage 1 of this form. "AE I also certify that I have prepared this application and that the work to be performed will be donaDilRTM=Rd$nge With all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JAN 211997 APPLICANT'S SIGNATURE UIN COUty'i-Y PUBLIC HEALTH SERVICES Title Date: N1VIR9A4YE ,TNL F9EALTH DIVISIOr,i AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. .c�'ClZlJ Nature of Service Request: r Service Code . Assigned to Employee # C ® Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 7 LJ Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By Yy 3 A Q�/-A_/�' SUPV _/ / ACCT / / UNIT CLKr3 El