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OWNER/OPERA7OR DBA ADDRESS CITY F APN # L'tt of S7ocktw 2 BILLING PARTY PHONE #1 ( ) PHONE #2 ( ) STATE ZIP ILand Use Application # IBOS Dist Location Code CONTRACTOR and/or � Q _ I y luck aFRYI P.F RF AHF RTDR �—+n: �''. ( i L BILLING PARTY Y �I w DBA yo n PHONE #1 (;L05i )�1�� oa D MAILING ADDRESS 1 6 ,J �x 17 9 7 FAX # ( ) CITY r R E S STATE T/7 ZIP `Y J 2a-) BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END 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. 1 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 Codes and S1/tt1a�rtle ds, State and Federal laws. APPLICANT'S SIGNATURE l�./LA1]L4 u.. Title: PlAlJt. t Date: 2 3 C1 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. Nature of Service Request: ( .I6,SGi%�1:.. Amount Paid SERVICE REQUEST 7Z. RVREQ) Revised 8/21/93 FACILITY ID Al nn !7 Employee # 6 / 3 / Date / RECORD ID # Date Service Completed / / Further Action Required: Y / N INVOICE # FACILITY NAME ( E JTA�OAl 4 / [ 'LING r PARTY Y / N SITE ADDRESS /767 t WT 0ANNFi LN IN CITY �� 1 DAI CA ZIP OWNER/OPERA7OR DBA ADDRESS CITY F APN # L'tt of S7ocktw 2 BILLING PARTY PHONE #1 ( ) PHONE #2 ( ) STATE ZIP ILand Use Application # IBOS Dist Location Code CONTRACTOR and/or � Q _ I y luck aFRYI P.F RF AHF RTDR �—+n: �''. ( i L BILLING PARTY Y �I w DBA yo n PHONE #1 (;L05i )�1�� oa D MAILING ADDRESS 1 6 ,J �x 17 9 7 FAX # ( ) CITY r R E S STATE T/7 ZIP `Y J 2a-) BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END 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. 1 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 Codes and S1/tt1a�rtle ds, State and Federal laws. APPLICANT'S SIGNATURE l�./LA1]L4 u.. Title: PlAlJt. t Date: 2 3 C1 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. Nature of Service Request: ( .I6,SGi%�1:.. Amount Paid Service Code Payment Type Assigned to l 4.4 6010-r nn !7 Employee # 6 / 3 / Date / / Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 7ag fee Amount Amount Paid Date of Payment Payment Type I Receipt # Check # Recvd By r9L3 on, w d- a4 7ag REHS _// SUPV _//_ ACCT /_ UNIT CLK _/ /_