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�r V SERVICE REQUEST (SERVREO) Revised 5/13/93 FACILITY 10 # RECORD ID # BILLING PARTY LV N FACILITY NAME /' C"/I( ' (�F SITE ADDRESS //Oz 7'/,7;q CITY SZ6�CON CA ZIP fSZab OWNER/OPERATOR �i t� f W4 ,,, ("od BILLING PARTY / N DBA " v� D f�"/fY�2 � 61 PHONE #1 (�) ADDRESS V//Z tTUJRO A �y PHO/NE #2 ( ) CITY �CG�IEZoN STATE ZIP 9�Z06 APN # Census --------- BOS Dist Location Code City Cade ---•-- CONTRACTOR and/or �� SERVICE REOUESTOR 20 ` BILLING PARTY Y / 97 DOA (�p 1�vI F/d} (Z PHONE #1 (�) y- LS MAILING ADDRESS ar-i ✓—ww FAX # (�12-51- QST CITY AOW8 y STATE _7._ ZIP 9S3 rI 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. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. APPLICANT'S SIGNATURE A:� V N Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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. Nature of Service Request: I Service Code Assigned to Employee # Date / /, Date Service Completed _/ / Further Action Required: Y / N 1PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS _//_ SUPV _/_/_ ACCT _/_/_ UNIT CLK _/_/_