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SERVICE REQUEST (SERVREO) Revised 8/23/93 FACILITY 10 N RECORD II) K -. INVOICE rACILITY NAME /(//^n /"F // '' + 11 giLLI[G) NO PARTY Y / N S1TE ADDRESS LJ 9V CDo�.l fV e I JU CITY Sl c) (t bN CA ZIP ,5-a 0 1 OWNFR/OPERATORBILLING PARTY V Y / N Po &x bD I Y _ TRR sT,> N&^ � DBA I /_ (,/ �•- PHONE K1 J '.^DREss L V d &) PHONE #2 CITY 5�oc STATE ZIP FAPNK pLerd Use Application N -- BOS Dint Location Code SERVICE IDR UT OR I T�� q I /^ �I�p SERVICE REO�TOR I/ `Ili IT(?CA � _---L11J l BILLING PARTY (�'�! / N DRA �� PHONE KI (vR 0 (1' �)�F- UG� MAILING ADDRESS kol( TAX N ( ) CI TYSTATE _ ZIP 953�5—/ RILU NG ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of name, acknowledge that all site aril/or project specific PIIS/EHD hourly chergeR associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Pnge I of this form. I nlso certify that I hove 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 Title: Deter 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 as It Is available and at the same time It to provided to me or my representative. Nature of Service Request: Service Code r ` Q 7 Assigned to �[J.l u1 ll�.�\\ \SON Employee N L O � Date 1�/�/ 1-' NI Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Q� Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By a3� RENS / / SUPV / / ACCT / / UNIT CLK s �