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ACILITY ID R FACILITY NAME C3 SERVICE REQUEST RECORD ID # ('.4 Gf -soS (EM 00 61) Revised $123/93 INVOICE # BILLING PARTY N SITE ADDRESS CITY Lcs LL\ �._ CA zlPz OWNER/OPERATOR C ,C` S V (0y\_3 `"N9,- DBA ADDRESS 4'-Q) BILLING PARTY Y N PHONE #1 BILLING ACKNOWLEDGEMENT: 1, the undersigned Owner, operator or agent of same, acknowledge that all, site and/or project specific PHS/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 the work to be performed Will be done in accordance with all SAH JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLIC'ANT'S SIGNATURE ��1HI Title: k l Date: 2 MAR i 19 98 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, When applicable, 1, the owner, opeF i��1{lent of same, of arty en the property located at the above site address hereby authorize the release of d ell results, geotechnieal data and/or"' environmental/sfte assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E AqM�� a it is available and at the same time it is provfded to me or RN representative.HEALTH DIVISION as soon as . Nature of Service Request: i S v Assigned to 6 Employee # —. . SAN' Date Date Service Completed / PUBLIC �- �E7pi1rr_ f Further Action Required: Y E�IVIRWNME T1�06MMA IELB}fENT,.,� Fee Amount I Amount Paid RENS _/ / SUPV Date of Payment(Payment Type f Receipt # + Check # Recvd By �/ ACCT / J UNIT CLK _/�/ HONE #2 CI TY APN # ` �o \ STATE zip Land Use Application # �— BOS {list Location Code CONTRACTOR and/or SERVICE C REQUESTOR RILLING PARTY Y J H DBA PHONE #1 MAILING ADDRESS \ ]Q CITY FAX * f } �* STArE =a z I P BILLING ACKNOWLEDGEMENT: 1, the undersigned Owner, operator or agent of same, acknowledge that all, site and/or project specific PHS/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 the work to be performed Will be done in accordance with all SAH JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLIC'ANT'S SIGNATURE ��1HI Title: k l Date: 2 MAR i 19 98 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, When applicable, 1, the owner, opeF i��1{lent of same, of arty en the property located at the above site address hereby authorize the release of d ell results, geotechnieal data and/or"' environmental/sfte assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E AqM�� a it is available and at the same time it is provfded to me or RN representative.HEALTH DIVISION as soon as . Nature of Service Request: i S v Assigned to 6 Employee # —. . SAN' Date Date Service Completed / PUBLIC �- �E7pi1rr_ f Further Action Required: Y E�IVIRWNME T1�06MMA IELB}fENT,.,� Fee Amount I Amount Paid RENS _/ / SUPV Date of Payment(Payment Type f Receipt # + Check # Recvd By �/ ACCT / J UNIT CLK _/�/