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SERVICE REQUEST {y (EN 00 61) Revised 8//23/93 <br /> FACILITY ID # I �L7(,1gr1$�lo RECORD ID # / INVOICE # <br /> I F L(- �� ���P� BILLING PARTY Y / <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY K//lI�t7 Y/`�' CA ZIP -� ✓`-�'1'� <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # p Land Use Application # <br /> I FS Oist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR <br /> DBA <br /> f\ ���.� tcUG///ll(/V PHONE #1 (� '�L) )ice i - <br /> ` zXn <br /> � �(� <br /> MAILING ADDRESS /{ /V7-7D /1/' �h�l�C'/<-- � PFAX # (<--fo <br /> CITY STATE �_ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. ��pp i <br /> I also certify that I have pre r d this application and that the work to be performed will be done in a ¢1�Fyt�alll SAN <br /> JOAQUIN COUNTY Ordinance Cod ards tate and Federal laws. IP 1°�°'� <br /> p `7 <br /> APPLICANT'S/SIGNATURE 6 <br /> Title: J//L v /Gly/.ifs/�' Date: <br /> S`\g�\G aalp <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator oRegFo`f same, of <br /> the property Located at the above site address hereby authorize the release of any and all results, geote; at data and/or / <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH at <br /> as soon as J/) <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Sprvice Request: Service Code i <br /> Assigned to TD, [TCkn-n-,-_ Employee # 1 L �� Date LL—/�,_/, � <br /> o - <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS SUPV - _/ /_ ACCS_. /:X'��,/ UNIT CLK <br /> �. !. <br /> U <br />