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SERVICE REQUEST (SERVREQ) Revised 8/23/93 FACILITY ID # RECORD ID #T D ` V0 INVOICE # FACILITY NAME BILLING PARTY Y / f N/ SITE ADDRESS V1 �J CITY CA OWNER/OPERATOR BILLING PARTY (Y 1 / N DBA PHONE #1 ( )bCA ADDRESS 1(0-25�. � I��—�T I Ili� PHONE #2 ( ) CITY STATE _ ZIP J �tCJ APN # ELand Use Application # Ul qG— BOS Dist Location Code CONTRACTOR and/or SERVICE REUUESTOR BILLING PARTY YL"' _.,. I . / N IN DBA �� ASSOC. PHONE #1 MAILING ADDRESS G�� 6 �, �� FAX ,b3 _ CITY f L STATE ZIP SZ U BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also 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 : PAYML1V°r Title: Date: OCT — o inSAN �r AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, theikw r �We A.t9r or L► A� -'�tIO� LAgent of same, of the property located at the above site address hereby authorize the release of any ar��A �e� vts��f��otcIr� lqdata and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENrTAh 4EA!`TPLDbVfS[ON as soon as it is avaitabte and at the same time it is provided to me or my representative. 'V'SION Nature of Service Request: Service Code Assigned to Employee # (7:;7_ Date Date Service Completed / / Further Action Required: Y / N FPROGRAN ELEMENT Free Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS I C�3/ i d/ 4 SUPV _/ / ACCT 10/ 10 i O z�cf�