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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BiLLINC PARTY Y / N <br /> FACILITY NAME J # <br /> AID # <br /> SITE ADDRESS <br /> CITY �� �fl AT CA ZIP FAC �0 7 <br /> OWNER ERATOR ���� vYl/�� BILLING PARTY Y / N <br /> DBA (, / /� PHONE #1 ( ) <br /> ADDRESS ��j�X//(J'"J �� PHONE #2 <br /> CITY /A/ STATE ZIP <br /> APN # Census •-•------ BOS Dist Location Code City Code ----- <br /> CONTRACTOR and/or / i �h��J o <br /> SERVILE REQUE STOR /'�vs, /7e� _ �/ �-d//�� �' BILLING PARTY Y / N <br /> DBA PHONE #1 am•. <br /> MAILING ADDRESS -7Di� �0-�� ' FAX #n( ) <br /> CITY �� ��EC�J��— STATE .. ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/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. <br /> 64 <br /> I also certify that 1 have prepared this application and that the work to be performed kiM rb¢'i aMd rt-accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. �� `'le <br /> APPLICANT'S SIGNATURE A P P O `r IN <br /> Date: (nM��E LIC Fi t;Af Ttl <br /> Title: IR�r--'-111^C HLALTt•1 plVW10N <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Berv'ce Request: Service Code <br /> Assigned to Employee # y Date <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 /> RE4S I _/_/_ SUP'. _/_/_ ACCT I _/_ _ UNIT CLK _/_/_ <br />