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0 SERVICE REQUEST 8 (EH 00 61) Revised 8/23/93 FACILITY NAME III SITE ADDRESS SA) I,,3PF&e n f LA> rO,3 CITY XA f i I' /Q CA ZIP 9 Sn o BILLING PARTY rIAYMPNT OWNER/OPERATOR / A/ � C /S IOM �,t�Co ,�Fy$ �.` BILLING PARTY A 4kyA f7N V l h iV �/D hd/SoiY k PHONE #1 ( ) Pl� ADDRESS L 88� L'I I�., PHONE #2 (%D 7) Jy b S - D E 7 CITY tG/{�IG�/-1 ` STATE # Land Use Application # CONTRACTOR and/c SERVICE REQUESTC .0A ZIP 9 VE BOS Dist Location Code BILLING PARTY Y / PHONE #1 (209 )22L- /Fo'/ MAILING ADDRESS /��' P / l o y ! 3 � Z / FAX 4 # (oZ�).Z /0 9 CITY Ee 155&1 STATE Cd _ ZIP % �j Y / -7 % 2 BILLING ACKNOWLEDGEMENT: I, 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 identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that JOAQUIN COUNTY Ordinance Codes and Standards, State And Feder PAYMENT work to be performed wilt be done in aci:RWa WIRi*14. 11 SAN SEP 2 81995 APPLICANT'S SIGNATURE oAN J UBLIC LTH R H Title: Date: :�%NVIRONMENTAL HEALTH �D TV ISIL�j . 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 data and/or environmental/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: Assigned to Date Service Completed —/—/, Employee # Further Action Required: Y / N Service Code U 3 1 Date PROGRAM ELEMENT Z3. 60 Fee Amount Amount Paid Date of Payment 115 Receipt # Check # FACILITY ID # RECORD ID #1 1 3 INVOICE # I 7 FACILITY NAME III SITE ADDRESS SA) I,,3PF&e n f LA> rO,3 CITY XA f i I' /Q CA ZIP 9 Sn o BILLING PARTY rIAYMPNT OWNER/OPERATOR / A/ � C /S IOM �,t�Co ,�Fy$ �.` BILLING PARTY A 4kyA f7N V l h iV �/D hd/SoiY k PHONE #1 ( ) Pl� ADDRESS L 88� L'I I�., PHONE #2 (%D 7) Jy b S - D E 7 CITY tG/{�IG�/-1 ` STATE # Land Use Application # CONTRACTOR and/c SERVICE REQUESTC .0A ZIP 9 VE BOS Dist Location Code BILLING PARTY Y / PHONE #1 (209 )22L- /Fo'/ MAILING ADDRESS /��' P / l o y ! 3 � Z / FAX 4 # (oZ�).Z /0 9 CITY Ee 155&1 STATE Cd _ ZIP % �j Y / -7 % 2 BILLING ACKNOWLEDGEMENT: I, 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 identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that JOAQUIN COUNTY Ordinance Codes and Standards, State And Feder PAYMENT work to be performed wilt be done in aci:RWa WIRi*14. 11 SAN SEP 2 81995 APPLICANT'S SIGNATURE oAN J UBLIC LTH R H Title: Date: :�%NVIRONMENTAL HEALTH �D TV ISIL�j . 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 data and/or environmental/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: Assigned to Date Service Completed —/—/, Employee # Further Action Required: Y / N Service Code U 3 1 Date PROGRAM ELEMENT Z3. 60 Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By OCA SUPV//_ ACCT / �Q/ REHS SUPV//_ ACCT / UNIT CLK