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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # ' / RECORD ID # (�O O� INVOICE # <br /> FACILITY NAME Oh US BILLING PARTY Y N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # I pLand Use Application # <br /> 1�r � � ^� p BOS Dist Location Cade <br /> CONTRACTOR and/or �J -� y^ <br /> SERVICE REQUESTOR)C �Toc�ceri� lrCi�t� d / nBILLING•P�AR4T•Y Y p/ N <br /> DBA �+ (/• . 144 6k"A',,,,,, D 0 PHONE #1 (/"( ) -- O <br /> MAILING ADDRESS Z�do /v /`T-`/ FAX # ( ) <br /> CITY S" !�`� STATE ZIP <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 billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accoRancg'yi,fh �SAN <br /> JOAQUIN COUNTY Ordinance Codes and Ste rds, State an f eral laws. II VVVVV <br /> ?(APPLICANT'S SIGNATURECIL v 42003 <br /> Title: ��, Gi✓� l E�9inee-� Date: A34J0AoU1N COUNTY <br /> HATH DEPARNTMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sane, 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 available and at the same time it is provided to me or my representative, p <br /> Nature of Service Request: _ Service Code p <br /> Assigned to ,�:AEmpIoyee # �60 <br /> Date o <br /> Date Service Completed Further Action Required: Y � PROGRAM ELEMENT �0 9 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> f�6• 1 �6� 11 ( Y(D3 ✓ <br /> REHS ZL/ �J' / ,..3 SUPV _/ /_ ACCT <br />