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FACILITY ID # <br />RECORD ID # <br />Payment Type <br />-#-- <br />INVOICE <br />Check # <br />FACILITY NAME <br />SITE ADDRESS <br />CITY P+(f oN CA ZIP s340; <br />OWNER/OPERATOR 1ZI PON MI L W IC, <br />DBA J. <br />ADDRESS S� <br />CITY <br />APN # <br />CONTRACTOR and/or C i ',� <br />SERVICE REQUESTOR of <br />DBA <br />STATE <br />Land Use Application # = <br />ZIP <br />MAILING ADDRESS <br />BILLING PARTY c Y�; / N <br />PHONE #1 ( ) <br />PHONE #2 () <br />BOS Dist Location Code <br />BILLINGPARTY Y <br />PHONE #1 ( rL7v1 )S4- <br />FAX # )d,0- 0053 <br />CITY M0 -r6 STATE e^ ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sane, 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 Cod9P and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />Title: (�(,tt/L ln. Cn.SM/I-� h,(;Nry Date: b-72?7- y <br />u <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and ell results, geotechnical data arid/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: <br />Assigned to VtiUe*,ae ( , Employee # (A W <br />Date Service Completed _/ / Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT --,?) -.ad <br />Fee Amount <br />Amount <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />�iPaid <br />d <br />ACCT <br />UNIT CLK <br />_jam_ <br />WJ <br />SUPV J_/_ <br />ACCT <br />UNIT CLK <br />_jam_ <br />