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II� r . £ 8/23/93 SERVICE REQUEST (EH Ob 61) Revised :r{ FACILITY IO # RECORD 10 # INVOICE # F4 lfti � G PARTY Y FACILITY NAME RE SITE ADDRESS CA 1995 / N l 71P UIN 'CITY OUN PLBL1CHEALTH SERVICES 4 ENVftNMF:NTA! OWNER/OPERATOR BILLING PARTY Y / \ ►+J r � PHONE #1 DBA ! 02 1�� ADDRESS � � � � PHONE #2,�) •T';' CITY — STATE ZIP �/ y Land Use Application # BOS Dist Location Code dONTRACTOR and/or f / SERVICE REQUEST^� `r BILLING PARTY Y N ,—� C A f` PHONE #1 FAX # ) - ', MAILING ADDRESS / _ f =; r CITY U 1! STATE zip ` �� Lr s ` ty BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that alt site and/or project specific PHS/EHD hourty charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. p qy MENT I also certify that 1 have pr Ared this app i tion and that the work to be performed will be don4RF51=1MF1R with all SAN JOAQUIN COUNTY ordinance Code Stand r s ate Federal laws. MAY n 2 199 5 ° :•APPLICANTIS SIGNATURE „ UBLIC HEALTH SERVICES Title: Date: AI-.HEALTH DIVISION 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 environmental/site assessment information to SAN JOAQUIN COUN7Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as t< �- it is available and at the same time it is provided to me or my representative. Service Code Nature of Serv'ce Request: FEmployee # Date Assigned to ,-, pate Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT k; Fee Amount Amount Paid Date of Payment Payment Ty Receipt # Check # Recvd By OW RENS / / SUPV / / ACC - UNIT CLK �/ /