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n �/ SERVICE REQUEST i (SERVREO) Revised 8/02/93 FACILITY ID # RECORD ID p# 1 INVOICE # FACILITY NAME ,?)() �,{// �`/ �L/IA J�Z/n�11��C/1 J^ BILLING PARTY Y /� SITE ADDRESS 111,7 /I/ Ip y/h#11-) /\��/ _n CITY �!(/ - //// _ - _ CA ZIP OWNER/OPERATOR BILLING PARTY Y s DBAI \ Dfy/Y1/�.0 J/�.(�PXJ PHONE #1 ( ) ADDRESS (LCl /V �I ,Ll" PHONE #2 CITY - STATE ZIP APN # / Census --------- BOS Dist D Location Code / City Code ------ CONTRACTOR and/or / SERVICE REGUESTOR T,./i/ BILLING PARTY Y / N DBA rA,1' G/s�/,/—/7✓J ��L�ll� PHONE #1 �V )�S - 1717 MAILING ADDRESS Yi_n FAX # <T) CITY (5J1W � �Q-mss STATE ZIP s BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge t l site and/or project specific PHS/EHD hourly charges associated with this f ility or activity will be billed to t rty identified as the BILLING PARTY on Page 1 of this form. I also certify that 1 have prepared t s lication and t e w�tobeformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and S rds, Stat Federal laws. APPLICANT'S SIGNATURE Title: K Date: AUTHORIZAT TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the rty 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: Service Code Assigned to Fs�viJ s Employee # fid' Date Y / /�, /98 Date Service Completed _/ / Further Action Required: s / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By EE: ENS _/_J_ SUPV _/_f_ ACCT _/_/_ UNIT CLK _/_/_