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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # 0 13 76 INVOICE # 1G� ; 1 2,4- FACILITY 1lAMECLT14 OC' \0ACt= �A}l�u°SS:t Quaa? Si�FAzkl!,,� �Ayt BILLING PARTY Y / N SITE ADDRESS \401-1DL CITY ^^TkA S CA zip 'i OWNER/OPERATOR l-�T`I Oo- l ii>AC!4_ BILLING PARTY Y / G DBA UJASzf C 11 a E',2 1 Pe.a^ cvi>?vi r�/yv PHONE #1 ( 2" `i ) t - 'v Y ADDRESS 39 00 01.(.4 PHONE #2 (� U � ) c: 1 - LI Y C' CITY STATE ZIP -1 J i C, p APN # Land Use Application # IBOS Dist Location Cade CONTRACTOR and/or - SERVICE REQUESTOR ernaij,, 12t1/-,�, E4 y` tiAt, 96u i C S �_ JC BILLING PARTY / N DBA PHONE #1 ( zo4 ) P s3 _ a (� MAILING ADDRESS ti ZZC \Z W1M rip I(-Il ha! f #(�l��, FAX # ( �o`t_> 63L- S1� z CITY 11-41-%,CSTATE `N ZIP qS .3 �6 BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party ideAtiified as the BILLING PARTY on Page 1 of this form. fPA I also certify that 1 have prepared this application and that the work'to..be performed will J ! 5'toflfance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. C 2 5 997 APPLICANT'S SIGNATURE BANJOAO �, IRONAIEMAL HESERVICES, DIVISION Title: l''Z�—tci �1/JNAG E2 Date: g `LS—5� 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 environmenta L/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: ! CL Service Code Assigned to D L;!= f � \k-a-f�Eaployee # L �� Date —q—/ (_ Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT zi 3 Z-)� 7,-' Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By �3�f. J_ /aS(q ✓ ai8 t L45 RENS � / / `S SUPV /_J_ ACCT I L'1 L'�/ .�`G' /_ UNIT CLK .o lam, r