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SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID 7 INVOICE # ,/�35p,37 <br /> c �- Ev �i <br /> FACILITY NAME JC�I.i 11�i,/-!TJ 1_� <br /> BILLING PARTY <br /> .r ., <br /> I. z c' �t• ••,� ( � � <br /> SITE ADDRESS �/ ,�" '.J •.� . `��I`�i� I�Jti�Tt-= I ��i✓_rT;�-TfgcY.�� � �c> <br /> CI-TY C-i'�(iCk—(U1J G ZIP <br /> OWNER/OPERATQR C�La)�I�L-f\IJ 1� LJ;i f?l BILLING PARTY .Y / [F1 <br />` DBA {7 PHONE #1 ( .Sul% ) (r L - <br /> r L�T I l <br /> ADDRESS jC�'�� �3IL1-SGV-I�C�I� 1- I I'-ti I� > ��V PHONE #2 ( ) <br /> CITY Y ICI "�/�1•-��L' 1, STATE ZIP <br /> pAPN N �Land Use gpplicotfon <br /> # <br /> II BOS Dist Location Code EJ <br /> CONTRACTOR and/or tt <br /> SERVICE REOUESTOR I'l +LV � Ca'!�/(L T BILLING PARTY GTV / N <br /> DBA .r Ii. �C,SI C�J.> C?.jL-li•v'� PHONE #1 ( lam) J 7 -AD-c.)3 <br /> NAILING ADDRESS ly / µJu Jf= - 1 15,-b-i Oq <br /> `l. <br /> CITY -> wt�.it-7-T�i STATEZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EIID 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 /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and <br /> �Stand ard Stat and Federal laws. sPAYMEN 11 <br /> APPLICANT'S SIGNATURE : � �f I 91 <br /> rr � i 1y9� <br /> Title: {�P1�1 , f � `1'y�(�LiQt�ll� Deter l41 L�'AN JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the o _ i�fb�Fo{IIT��riN=6F'Iy1F(�, of <br /> the property located at the above site address hereby authorize the release of any and al lwresults, �iEtl cent <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 Servi Req est: n Service Code Q-3 <br /> Assigned.to Employee # l l J Date _ -/—L�14].9 7. <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 /> Z <br /> n i <br /> RENS SUPV _/_/ ACCT / J UNIT CLK _/_J_ <br />