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ltrj SERVICE REQUEST --�.- (SERVREQ) Revised 8/23/43 <br />FACILITY 10 0 <br />Amount Paid <br />RECORD ID R7 <br />7 4 INVOICE R <br />Receipt N <br />C K�� (( c4�7`' (-yam ` t�T F�, /LJL <br />FACILITY NAME Sf fp' � �!P-\1),-1t5 ✓�`I"T,�ncW F-5 gILLINQ PARTY Y / N <br />SITE ADDRESS 301 t (i��, F)C 1wUTim IN 7 IOLT []-I Q( <br />CITY S:Mcj f� CA ZIP _15209 <br />nWNFR/OrERATOR He u- OIL- trl/l`Yl PA 1 BILLING PARTY Y / N <br />DBA C A ciL4 52L-{ PHONE rt (5I0 ) 615- 006 <br />ADDRESS 1390 WILLOW_. �FtSS "0 . SUrre--* (Dion PHONE ez (510 )-615 - (14( <br />CITY cx>NCORD STATE CA - <br />a —r=Land Use Application k <br />zip 94-520 <br />711 BOS Dist Location Code <br />CONTRACTOR and/or A GFLN C, <br />SERVICE REQUEST.,,r/1tLA_FG-stn`It .(�/NS1tIX'TrO1J k EN �11RWpIBILLING PARTY Y / <br />DRA PHONE 01 ( 510 )4'42-- <br />2484v4 <br />MAILING ADDRESS 5079FxCLIAw 2 COKE FAAX#(510 r- 17 <br />CITYMSTATE CA, ZIP 94550 _ <br />SJr! A,.°✓ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that attFpk taritfor :protect specific <br />PNS/EHD hourly charges associated with this facility or activity will be billed to the party i The n BILLING PARTY on <br />Page 1 of this form. 21995 <br />JAI" JC)AQL),, , <br />LP nca with ell SAN <br />I also certify that t have prepared this application and that the work to be performed l��IFf��6i111�pLaR9gr <br />JOAOUIN COUNTY Ordinance Cods e��terxjards, Stet Federal laws. ON <br />1/1L 11\� 1 QQQ ND <br />APPLICANT'S OC.�SIGNATURE <br />Title: `Nl71N <br />/6/7g- CDOFL�T�:�) <br />AUTHORIZATION 70 RELEASE INFORMATION. In addition to the above, when applicable, I, the owner, a <br />the property located at the above site address hereby authorize the release of any and ell result <br />envfrornental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIEN <br />It is available and at the same time It is provided to me or my representative. <br />Nature of service Request: ( I &CL�) cr �T Service Code <br />Assigned to J,, � �QA"", Employee N Date <br />Date Service Completed / _/ � – Further Action Required: Y / O PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check # <br />Recvd By <br />?cz <br />�C/ <br />RFHS I _//-I SUPV 1 _/_/_"CCT I _/ 1I CLK I _/_/_ <br />L% <br />