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-�l - SERVICE REQUEST � � SERVREG) Revised 8/23/43 (FACILITY ID 11 I I RECORD ID # I I INVOICE N IACIL ITY NAME /_ _�Y (LTJ ` i f I ti 75 BILLING PARTY Y / N SITE ADDRESS J0/ �/ r �� l� -T4 l) 6I L , CITY j/C�CA ZIP OWNFR/OPERATOR) DRA V\C c-40� [BIING PARTY Y / N PHONE 01 ( )�a-- ADDRESS �� i1�I� PHONE #2 ( ) CITY STATE_ ZIP - APN # Land Use Application # BOS Dist Location Code CONTRACTOR nd/or \ T SERVICE REQUESTOR _ BILLING PARTY Y / N DBA PHONE 01 ( 07 f-'�-t-- 'I 3 3 MAILING ADDRESS FAX # (_)-- CITY , OC,(C-10e�3 )- CITY,OC,(C-10c%-�3 STATE �� ZIP t RILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PIIS/END hajrly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page i of this form. 1 nlso certify that I havepared is application and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinanc'p; and S rindards, State and Federal lbws. APPLICANT'S SIGNATURE Title- Date• 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 date and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon es It is available and at the same time it Is provided to me or my representative. Nature of Service Request: %�'1��r�_ Date of Payment Service Code Receipt # Check # Assigned to l C �i�� Cif Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT J Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By ::�13`�00 -:�) 3e-1. X3610 WL REHS / / SUPV _/ / ACC/ / UNIT CLK D