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• SERVICE REQUEST , (BERYREO) Revised 8/23173 <br /> �. AI •L,'Ty [D RECORD lD � �— INV63CE $ �. <br /> 74CILITY NAME �c1 J1� BILLI� yt1� <br /> SITE ADDRESS � !^^C�O� LV. `/ <br /> CITY s--tJ�L. CA 21P yd, <br /> wurR;on=_RA7oR _ G`Q- l7 • /� B1LL)NG pAafT LJ / N <br /> DHA t�4t-�t-C (.GLc,. .(,lt.X-C�'�dri_ , PHCME 01 <br /> ADDRESS 8J o- al. <br /> CITY STATE ZIP <br /> I--=APN k -- — Land Use Application At <br /> r Y <br /> I, BOS Dist <br /> ::)NTRACTCR and/or <br /> ;CRVICE REouESTOR <br /> -.sNar�mrticas:mw. <br /> DBA _ DEL T f/ PNONE #1 (: <br /> `'AIL IN,, ADDRESS <br /> FAX/ P17- -77 <br /> CITY <br /> STATE L0._ ZIP I3 .� <br /> 3i LLiNG ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specfffc <br /> PHS/ENO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pape I of this form. <br /> 1 also certify that I have prepared this application atd that the work to be performed will be done in accordance with aLl r.a;. <br /> ;OACUIN COUNTY Ordinance Codes nd Standards, State and Federal laws, <br /> 'PPL I CANT'S SI GNATUR : <br /> . . ":t7ATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> -operty Located at the above site address hereby authorize the release of any and all resuitsf geotechnical data arwor <br /> m*n AI/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon ss <br /> .a avaitahle and at the same time it is provided to me or my representative. <br /> .re of Service Request: ..GIt.G-L 01 YService Coos <br /> i m <br /> .. TY"d to ---_4 „G`.�..e.v._ EapLoyee M l,.a r 7 Date <br /> i 1 t/ F,e"� qr l;C t n + 1d f i FROi;IV,N LE?1EOfT <br /> caro Service Crnmleted J / f ' t_O,. R iST^A Y <br /> r„e Armunt Amount Paid Date of Payment Payment Type Receipt R Check A` Recvd By k <br /> 22 z 0 <br /> Sl1PV �l�f__s'ACLT ! �j„ /,�_ UNIT CLK /_/^ <br />