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SERVICE REQUEST (Ell 00 61) Revised 8/23/93 FACILITY ID X INVOICE X ill.../// •J} FACILITY NAME �L O� — � LL BILLING PARTY Y / N r GCS .5 SITE ADDRESS 1S S CITY l B� _ b'1( CA ZIAP OWNER/OPERATOR �L D� �/O G.�7�'n7 A / /�C11/G BILLING PARTY Y / N DBA PHONE A7 ADDRESS '7 ZS / V 11�` r�Q�J 5: �,��r /TGG-- PHONE 02 ( ) CITY �` O C�702'l STATE C.f7 ZIP �APN X p Lend Use Application X DOS Dist Location Code CONTRACTOR and/or C SERVICE REQUESTOR y211Q G/✓/J �it/ y//✓' �1G r 1�✓c BILLING PARTY / H DBA PHONE MAILING ADDRESS199s�`s- FAX A CITY 4.(l �f�Tl�/^/I�,y,AL STATE � ZIP p/�q/ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/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 I also certify that 1 have prepared this application and that the work to be performed will be done in aAFn.99 of SAN JOAQUIN COUNTY Ordinance Codes and Standard tete end ede ral 1at75. JUN 1.0- 1997 APPLICANT'S SIGNATURE f ` L SAN/ Q PUBLIC(HEALTH SERVI ES Title: �nla o n Dater C� `� �! ENVIRnNMENTAL HEALTH DIVISION , AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of sam, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data end/or enviroraental/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 are or ay representative. ',7 r Service Code Nature of Service Request: I tom / Z.�/�-y2 G Assigned to I �h Jilk, J . �lC 6 )/�Employee X Date �L/�/� a Date Service Completed _I—/— Further Action Required: -7 / N PROGRAM ELEMENT Fee Amount Aarount Paid Date of Payment Payment Type Receipt X Check X Recvd By -77 ACCT hA W / /� UNIT CLK / /_