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v SERVICE REQUEST 'e/' (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID it INVOICE # <br /> FACILITY NAME 0.>`r'ryywrNQ 1 (J�Si. �I�4r`r-CJc-4-p� D'ClX BILLING PARTY /VVV N <br /> SITE ADDRESS . — <br /> CITY Q -vnI� CA ZIP S Z- [ <br /> OWNER/OPERATOR BILLING PARTY Y / LNj <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> p APN # P Land Use Application # f�- _il�� BOS Dist Location Code <br /> CONTRACTOR and/or _ � l�z �l � l-p� BILLING PARTY Y / <br /> SERVICE OR UESTORand/or WtirrY an ..00�� <br /> DBA I ( I' PHONE #1 ( ) <br /> MAILING ADDRESS "' " a -a - Ck Q 'tiz� FAX # <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identiQd_aa theBILLINGPARTY on <br /> Page 1 of this form. 00MENT <br /> RECEIVED <br /> I also certify that I have prepared this application and that the work to be performed will be dorAR accordalpQC+ith all SAN <br /> SAN JOAQUIN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. ' 'FF1i l 00 O ''11 <br /> GQ4INTY <br /> APPLICANT'S SIGNATURE r. PUBLIC NFALTii ,9FRV^�1�FSS,^ <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environvental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Z. Service Code <br /> Assigned to C7��1 "" �-0� Employee # q `� U Date 3_/�/3� <br /> Date Service Completed 7/-al/R f Further Action Required: Y / PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUPV _/ / ACCT _ / /_' ,� UNIT CLK _/ /_ <br />