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SERVICE REQUEST _3 � P SERVREQ) Revised 9/23/93! i FACILITY ID X I I RECORD ID B I I INVOICE R I -! C)t) rACILITY NAME _ _� -LLL k -c_ �rL (.-� r L�s�l�� c` 11 LING PARTY Y I - / J SITE ADDRESS CITY 65 ZIP rrin7FR/OrERAtOR f4 ec� BILLING PARTY Y / N U L DRA / PHONE N1 S ADDRESS �0 �'v ' /��' l'YL_Z�-r•j1�Z`t� � Pimp N2 ( ) CITY STATE ZIP ArN NLend Use Application N BOS Dlst Location Code CONTRACTOR and/or SFRVICF RFOUESTOR /`k vr�-� d-1�� c .tea- 9- Gly-L�1h DBA MAILING ADDRESS 1,e- Zx / V -J LLING PARTY I ` % / N I PHONE NI ( /L )� L- 75-3S FAX 0 ( ) CITY G�'.� f �1 �u-��-� STATE C ALJ zip PILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that sit site and/or project specific PIIS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Pnq. 1 of this form. I nlgo 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 Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE : Title: Date: A1111IORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any end all results, geotechnlcel date and/or envirormentat/alte 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: Assigned to L-"4:-, Employee Ny Q8 ry i Date Service Completed / / Further Action Required: Y / N Service Code Date PROGRAM ELEMENT fee Amount Amount Paid of Payment Payment Type Receipt It Check N Recvd By C) C) �Date V �� V l �� /12j SUP/ _/ / ACCT / /� JUNIT CLK M2