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' SERVICE REQUEST . (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # INVOICE # FACILITY NAME J �'O BILLING PARTY Y / N SITE ADDRESS / ' CITY /4 CA ZIP OWNER/OPERATOR /�-GJ �L! T!/1Z:� BILLING PARTY Y / N DBA PHONE #1 ADDRESS D i A7 /I/-/(/G 9�7 /!� PHONE #2 �� CITY A-.Yli 7) � S ��SSTATE ZIP APN # p Lard Use Application # Il SOS Dist Location Code CONTRACTOR arid/or SERVICE REQUESTO BILLING PARTY Y / N DBA PHONE #1 ( l4/�G)�7L G- f- J Jldz_ -Js]L— MAILING ADDRESS �� er FAX # ( )37 Z CITY I�J� STATE ZIP 9t" 9l BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END 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 SAN JOAQUIN COUNTY Ordinance Codes and Standar a Federal Laws. �(/- /'' APPLICANT'S SIGNATURE �— • 6Y !7 l i zJw �2�T/' d 4 Title: 1-1e //G•.S. ✓ If3/�/J S r� Date: �// /r� S— V AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: L� � Service Code I Assigned tolo l/7i/ Employee # �DD Date V Date Service Completed _/ / Further Action Required: / N PROGRAM ELEMENT <Jn Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By (�v paw REHS �D/��/ SUPV _/ /_ ACCT _/_/ UNIT CLK _/_�_