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SERVICE REQUEST _ _ /5.7f#VREO) Revised 5/13/93 <br /> FACILITY ID NJ n RECORD ID # y� ,O PU ILLING PARTY � / N <br /> FACILITY NAME ry+�,LSCri���t?�✓1- �" 5a"N \TC I�.I�I �W Pn/ �U I <br /> SITE ADDRESS 3(, &- 1�o� 1 G EN D F�M j'rQ�. .IJC��1 <br /> CITY SGK-T �� �7�W C. <br /> rU N ZIP <br /> OWNER/OPERATOR 1 r}��-.LQ n---," I L G K 13, �, Jf+n7A r(— k1A11 ( IOA < C-O BILLING PARTY <br /> DBA � DO-YI- ECcW <br /> . '+///r � � PHONE #1 ( � kJ� <br /> ADDRESS (( � 7q-1 T^,FQ � r PHONE _#2)( <br /> C I TYSTATEZIP <br /> APN # Census --------- SOS Dist Location Code City Code ------ <br /> i <br /> CONTRACTOR and/or J ,, <br /> SERVICE REQUESTOR �eS+ -Sf-fa IZ �i' I) i R-dn-✓h s'L-l�'-q_.I .^ BILLING PARTY Y i p/ N <br /> DBA \\.1,CZtl,�ce //ioLC v PHONE #1 (-CO 9 )�l5- / 3SCY <br /> If <br /> MAILING ADDRESS 6e FAX # <br /> CITY MfaDeK4 STATE C.iJ ZIP /o3 <br /> 37 <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 /> I also certify that I 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 Standards, State and Federal Laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 /> C �1� - <br /> Nature of Service Request: Lo'sLLre r C(� Service Code <br /> Assigned to Employee # Date _/ / /yam <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT '7J U•—' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd dy <br /> REHS _/_/_ SUPV _/ /_ ACCT \�/�/ UNIT CLK _/_/_ <br />