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c30(ted <br /> • � SERVICE REQUEST � (SERVREO) Revised 8/23/43 <br /> F <br /> iliTY ID 0 RECORD IDN INVOICE <br /> • rACILITY NAME�Fr-U (C�C—` hi'TT _ _ BILL INO PARTY <br /> SITE ADDRESS �f �lv_ My <br /> CITY F-ft�-�C CA ZIP9�e> � !� <br /> OWN /OPERATOR 7"n�� ��T`h BILLING PARTY �.�,/ / N <br /> ORA PHONE Mt ( 4? ) ZZ1 <br /> ADDRESS PHONE M2 ( ) <br /> CITY STATE _ ZIP <br /> -APNM Lend Use Application M <br /> BOS D1st Location Code <br /> CONTRACT mei/or <br /> VICE REOUESTORS"[T'y ---��r <br /> DBA PHONE 01 (Zo )f/ / '� <br /> MAILING ADDRESS 82oFAX 11 (i?V'P Sli <br /> ) _' l 'L <br /> � - <br /> CITY 5VU '� STATE ZIP <br /> • BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent 91-11116acknowledge thot ell s14 - I{-0 specific <br /> PHS/EHD hourly charges associated with this facility or sctivi J.K?+itl tw b�Ll3� to the party identified as the B'7L"�. PARTY on <br /> Page 1 of this form. 1 �g95 <br /> r1 rV <br /> I also certify that I have proper th a icatlon ef send that th tyork to he Perfor,wtFsrr;�oNill be done in accordance with al( SAN <br /> JOAQUIN COUNTY Ordinance c and Ste nd Federal ljENVIRONMENTAL HEALTH <br /> P�p \SEN`"` PERMIT/SE <br /> APPLICANT'S SIGNATURE <br /> RVICES <br /> U41 <br /> Title: <br /> 03A."(eA(-3CYe-Pc`70� Date: v �J <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 sane time it is provided to me or my representative. <br /> Nature of Service Request: f� 1 I (1 C �J �F Service Code <br /> O C <br /> Assigned to Iloyee N Q Ct b 3 Date <br /> Date Service Completed ( / 9 Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Receipt / Check 0 Revd By <br /> ACCT S/ UNIT CLK _/_/_ <br />