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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY NAME SITE ADDRESS CITY. " CA ZIP S ;L- b OWNER/OPERATOR _ DBA _ ADDRESS _ CITY APN� CONTRACTOR and/or SERVICE REQUESTOR DBA .I' STATE ZIP BOS Dist BILLING PARTY I Y N BILLING PARTY Y / N PHONE #1( )qqLl - G1 PHONE #2 (t-) C/0- go -)- RECORD -)- Location Code BIL ING PARTY Y / N PHONE A ( I ) - MAILING ADDRESS j��9 1 /W� YI�c_x� Y j (/�w {p FAX # (v ) CITY �'-1��` Y 1 STATE ` -1v— ZIP g5Z-b 1 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 Page 1 of this form. PAYMENT ��A/�Y±±M aE�ttNccTn^ 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordalRECRIVESQ! JOAQUIN COUNTY Ordinance Codes and Standards, State end Federal laws. MAY 2 11998 I APPLICANT'S SIGNATURE T HEALTH AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 = or ny representative. Nature of Service Request: Assigned to Date Service Completed / / Employee # Further Action Required: Y / N Service Code Date PROGRAM ELEMENT Z Fee Amount RECORD ID # (J is' DS INVOICE # Receipt # Check # Recvd By 17a . i FACILITY NAME SITE ADDRESS CITY. " CA ZIP S ;L- b OWNER/OPERATOR _ DBA _ ADDRESS _ CITY APN� CONTRACTOR and/or SERVICE REQUESTOR DBA .I' STATE ZIP BOS Dist BILLING PARTY I Y N BILLING PARTY Y / N PHONE #1( )qqLl - G1 PHONE #2 (t-) C/0- go -)- RECORD -)- Location Code BIL ING PARTY Y / N PHONE A ( I ) - MAILING ADDRESS j��9 1 /W� YI�c_x� Y j (/�w {p FAX # (v ) CITY �'-1��` Y 1 STATE ` -1v— ZIP g5Z-b 1 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 Page 1 of this form. PAYMENT ��A/�Y±±M aE�ttNccTn^ 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordalRECRIVESQ! JOAQUIN COUNTY Ordinance Codes and Standards, State end Federal laws. MAY 2 11998 I APPLICANT'S SIGNATURE T HEALTH AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 = or ny representative. Nature of Service Request: Assigned to Date Service Completed / / Employee # Further Action Required: Y / N Service Code Date PROGRAM ELEMENT Z Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 17a . REHS // SUPV _//_ ACCT _// UNIT CLK _/�_