COMPLIANCE INFO_1993-2007 - Laserfiche WebLink

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SERVICE REQUEST 3pZ EQ) Revised 5/13/93 FACILITY ID # C Q/ f ?i RECORD ID # �� U a 0 BILLING A TYL/ Y / N FACILITY NAME 0-0 Ue 00, /i --a CA,l CGc lI T - cl Cc I .� # SITE ADDRESS .31-w� CITY ��6_ CTU`i CA ZIP 61-5- 2-c7 i OWNER/OPERATOR l.C'tr.-e C0,11 r 7ack Receipt # BILLING PARTY Y / N REHS _/ / SUPV _/ / ACCT rlJ // DBA Ooye Con - PHONE #1 00 ADDRESS a ��_ PHONE #2 ( ) CITY �pL'�G/prr STATE C� ZIP APN # Location Code C d City Code ------ CONTRACTOR and/or / SERVICE REQUESTOR �2 s<iE/1-� l �z I've iJ /L'c+J =BILLINGARTY Y / N DBA MAILING ADDRESS CITY STATE ZIP PHONE #1 ( ) FAX # ( ) BILLING ACKNOWLEDGEMENT: I, 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 Page 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE : Title Date: 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. Nature of Service Request: �l Si.ve.i' f�Xl+'t ��P��`✓ Service Code _L)� Assigned to (, r.i �� J 7` Employee # �� 7 Date b / Date Service Completed / / Further Action Required: Y / N I PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/ / SUPV _/ / ACCT rlJ // - i�11U-11 REHS _/ / SUPV _/ / ACCT rlJ // UNIT CLK - i�11U-11