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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID RECORD ID # INVOICE # # qqq FACILITY NAME nJA�0G4L 5S S4aI BILLING PARTY Y / N SITE ADDRESS CITY �iaG�C7Z)-rl CA ZIP. OWNER/OPERATOR ONS �{ IYSSDC��/�S �iL�C BILLING PARTY {'' PHONE #1 ( 714 ),!211 DBA ADDRESS I.34`r Urn +L PHONE 02 ( ) CITY �/ .-QTR ��%4 STATE �_ ZIP /OZ 712L APN # p Land Use Application # IBOS Dist Location Code CONTRACTOR and/or BILLING PARTY Y / N SERVICE REQUESTOR PHONE #1 DBA MAILING ADDRESS I39fJ �fl"Z-�, /J,A yy _ _FA% # )5-73 CITY J/�1�i �/L'�} STATE 1?'� ZTP BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that aLL site and/or project specific PHS/EHD hourly charges associated with this faci Lity or activity wi LL be billed to the party identified as the BILLING PARTY on Page 1 of this farm. 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 C / and Standard State and Federal Laws. J ! APPLICANT'S SIGNATURE : Fes'// �-� Title: V1Cf Date: 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 environmenta L/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. Service Code Nature of Service Request: Assigned to Enployee # Date Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt# Check # Recvd By RENS _/�_ SUPV _/�__ ACCT �_/_ UNIT CLK