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SERVICE REQUEST <br />(SERVREQ) Revised 5/13/93 <br />FACILITY ID # RECORD ID # BILLING PARTY <br />FACILITY NAME <br />SITE ADDRESS <br />CITYCA <br />OWNER/ ERATOR <br />APN # <br />DBA <br />ZIP"/�4�CJ <br />BILLING PARTY CL -11 <br />N <br />PHONE #1 ( -6'? 7 <br />rj <br />ADDRESSZ� PHONE 92 <br />CITY % STATE L ZIP <br />Census --------- <br />------- SOS Dist Location Code City Code ------ <br />CONTRACTOR and/or/� <br />SERVICE REQUESTOR ' I�TkD �ti- L � EERTY Y / N <br />DBA PHONE #1 <br />MAILING, ADDRESS: P, 5 0 C, FAX # )/4W— <br />CITY 4 C1 �Uly STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or projec`: specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I have prepa ication and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes a tandar , State nd Federal laws. <br />APPLICANT'S SIGNAATTURREr: <br />Title: <' Date: <br />v <br />d <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of s::me, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data .,nd/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a> soon as <br />it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to <br />Date Service Completed _/-/ <br />Service Code <br />Employee # Date -/-/ <br />Further Action Required: Y / N I PROGRAM ELEMENT <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />REHS <br />_/ / <br />SUPV <br />_/ / <br />ACCT <br />_/ / <br />UNIT CLK <br />