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FACILITY NAME \ JC/ SITE ADDRESS CITY OWNER/OPERATOR DBA ADDRESS CITY ea APN 0 s 1-� SERVICE REQUEST RECORD ID M H, Ile r Z f y ___ CA ZIP STATE Use Application N = ZIP BILLING �u tt ,��C�alsl—T11(%74« ,ust, a --jwV. 7 4 10 BILLING PARTY I Y / N PHONE M1 ( I PHONE MZ ( ) BOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR �OG I6 / �e 's 0I/ey /s` t� o/ BILLING PARTY Y / N DBA { 7�p P/✓rg/J"W^ L/Dl—qLIZ e4 BILLING PHONE M1 ( OS 1 %YZ - e6, 15 9 MAILING ADDRESS / �V (-3 �c//hCITY/V(7;V I; �� / 5 STATE !st ZIP f ® 3 S BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, 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 i have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance CodesandStandards, State and Federal laws. APPLICANT'S SIGNATURE : l-� �_✓ _� < title: �ru e , ^ lyn n Z Date: i 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. l , /Z k / ��\ ;[, �', Nature of Service Request: %P.. K C/°JI" Y' f .�� f i(4-ri ID n Payment Type Service Code Assigned to IJ i �hQ �7 (�' y / q,+_ Employee M " T �� Date /�/ Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check M Recvd By s 2 ��t Ol gaQS Old/ RENS _//_ SUPV _/ /_ ACCT _//_ UNIT CLK _/_/_