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y SERVICE REQUEST (SERVREO) Revised 8/23/03 FACILITY ID * RECORD ID * I INVOICE N ' l rACILITY IIA bQa V/ 4'91A Fe ILLING PARTY SITE ADDRESS � (� _ �AJ. CJ ]:)ng :)n �-A1./nA.�+ CITY �->�(�K-1-8v► �L�Jg J�L�CA ZIP T, "I QQ,� n --� �U U X //U�/L-1 U/CJ DNNFR/91'ERATOR � �/� /^ BILLING PARTY Y / N DRA T'OS �f/ /�/ a(!l/ZLL�.XiCl PNONE *1 ( ) S ADDRESS PHONE *2 ( ✓ ) CITY r/LG/L*/Lj STATE �'/ ZIP --APN * p Lard Use Application * IBOS Dlat Location Code J',FNITYAf D .mud/or SFRVICE REQUEST BILLING BILLING PARTYY / N DBA PHONE *1 ( y ) - /LyD NAILINf. ADDRESSFAX CITY STATE .` ZIP RILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/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. 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 Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 ardor environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION es soon as It Is available and at the same time it is provided to me or my representative. Nature of Service Request: I N Service Code Assigned to Employee * Date /_A / ph Date Service Completed / / Further Action Req red: Y / N PROGRAM ELEMENT-0 �/ Fee Amount Amount Paid Date of Payment Payment Type Receipt IN Check * Recvd By Alnll,oIv r � RFHS I __/_/ SUPV /__/ ACCT