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SERVICE REQUEST (SERVREO) Revised 5/13/93 <br /> [FACILITY ID # S - Q Q Q al-1A RECORD 1D # BILLING PARTY Y / O <br /> Q 5LZC'7 <br /> FACILITY NAME ` A-L <br /> j may,, <br /> SITE ADDRESS <br /> CITY CA ZIP7� <br /> L ( R/OPERATOR �= "r R'iI°� BILLING PARTY <br /> �f DBA PHONE #1 ( -570 ) <br /> r I U <br /> ADDRESS I. ` � �`� �Ly" PHONE #2 (SIO) S'22 ?7U <br /> CITY L-I /� STATE ZIP <br /> APN # Census -------- BOS Dist Location Code City Code <br /> ------ <br /> CONTRACTOR and/or <br />} SERVICE REQUESTOR I I <br /> BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> r <br /> CITY STATE ZIP <br /> i <br /> F <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> r I also certify that I have prepay this application and that the work to be performed will be done in accordance with all SAN <br /> P <br /> JOAQUIN COUNTY Ordinance Code Standards tate a er laws. <br /> APPLICANT'S SIGNATURE : <br /> Tit€e• Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when a cable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is availabte and at the same time it is provided to me or my representative. <br /> , , Itis' It <br /> Nature of Service Request: � ;.� Service Code 4G'j <br /> Assigned to Employee # ! 1s '= Date / / f <br /> ,k Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT <br /> IF <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> F <br /> EEHS _/ / SUPV _/ / ACCT _/ / UNIT CLK �/ / <br />