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SERVICE REQUEST <br />FACILITY ID # `% �� O RECORD ID # <br />FACILITY NAME I I �Ief) S <br />SITE ADDRESS <br />CITY <br />CA <br />C# <br />ZIP ! s 07- <br />ILLING <br />5M/43' <br />/ N <br />OWNER/OPERATOR /, T `M� l_ r 7 I A O � I f <br />DBA YX /�'�S�O�iS �r �1 h/��S� U16!V PHONE #1(a0✓f� )� �-/�%IS <br />ADDRESS C 1C -T S j PHONE #2 (D'A ) 5`T`7 - 3 yp 5 <br />CITY _� I (�() h! STATE �� ZIP _ 1� 5 3 ( <br />APR # I Census f--------- I BOS Dist <br />location Cade City Code ---•- <br />CONTRACTOR and/or c <br />SERVICE REQUESTOR <br />BILLING PARTY y / ��'1 <br />DBA <br />PHONE #1 Oct) l�) <br />MAILING ADDRESS �� ���� C�/yF�tfl� (� 2 FAX Qj U <br />CITY STATE C(1 ZIP <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 />I 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 Codes a^� Standaids, State aFederal laws. <br />`-I�-d (in —ni 1 I - � 6 <br />APPLICANT'S <br />SIGNATURE <br />Title: Y,�,L USC �I_'� _(� 7 <br />Date <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 to me or my representative. <br />Nature of Service Request: �)il �Ln IQ61 <br />Service Code 3 <br />Assigned to / "� I�I/1(1�( ��(-�� Employee #/�� `� <br />—1 i Dale/2 <br />Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # <br />P Check # Recvd By <br />=EH SUPV ACCT <br />/ UNIT CLK / / <br />