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., SERVICE REQUEST PAYM NT ised 8/23/93 *11110 FACILITY ID # RECORD ID # LL �INVoICERPR ll 9 �4Qf FACILITY NAME 11f11QA4 iBALiYI QIVI I[liV SITE ADDRESS CITY )�C'L'.k"�'r✓I CA ZIP 1�dl.Jl_rT-�'1�_1 OWNER/OPERATOR 5T0L-]-I' CP Cr nl0` BILLING PARTY Y / PHONE #i )�= DBA -� �� ADDRESS t�7l_ +r-ee4 PHONE #2 ( ) CITY C r-r rr n+0 STATE C- ZIP q5S 14 APN # FLand Use Application # BOS Dist Location Code CONTRACTOR and/or BILLING PARTY Y / N SERVICE REOUESTOR C7G�I L'IJ C� C `J �l 7T-L!C'M O'1 Qpq PHONE #t ( �)�_' 6: DBA MAILING ADDRESS F� O BOX -17ES - FAX # ( ito CITY l CO STATE ZIP �1Sga�► - BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific VHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page i of this form. I also certify that 1 have prepared this applic ion and hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Stand ds, a and ederal laws. APPLICANT'S SIGNATURE n �l_.1'e.Q. Date: z4- )-9(.P Title: - 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 me or my representative. - Service Code Nature of Service Request: Assigned to Employee N Date Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By UNIT CLK REHS _/__/__ SUPV _/_/— ACCT _/_/--