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e�y'n 39 Z-/ft ao�, as (EN 04 1Revis�fd N,23,93 SERVICE REOUE$T. FACILITY ID M RECORD ID M NVOICE k +t, 1 'fir^„-l.�1 � .s LUNG PARTY Y / N FACILITY WANE\� /��177�� SIIE ADDRESS CITY GA ZIP �7,� BILLING PARTY Y / N UWNER/OPERATOR PHONE N1Lf�f3 - DBA ADDRESS P—HOIN/E q2 ( ) APR 0Land Use Application M IBOS Dist Location Code CONTRACTOR anti/or BILLING PARTY SERVICE REOUESIOR 1`Il✓1 1 L (��/ 6-8 DBA PHONE q1 ,�r0 ) 'i/' - O -7 HAILING DRESS W� V I [/ / ' ` FAX H ( �o ADDRESS 1 CITY STALE ZIP BILLING ACKNOWLEDGEMENT: I, tine undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PIIS/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 JOAOIIIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE I it e• __ Dnte:_. AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of some, of the property located at the above site address hereby authorize the release of any and ell results, geotechnical data and/or environiental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the smile time It Is provided to me or my, representative. 1 Service Code _ Nature of Service Realest: Assigned to Employee N Date Date Service Completed _/—/— Further Actlan Required: Y / N PROGRAM ELEMENT _ Fee Amount Amount Paid Date of Parnent Payment Type Receipt K Check Al ±Recv=dBy _!_—.--___ SUPV ACCTUNIT CLK RE ItS I /—/—