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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # / -3 / INVOICE # !� 3 FACILITY NAME Z--- � D� BILLING PARTY Y / SITE ADDRESS ✓ ,v r` ' � C� —7�� CITY CA ZIP OWNER/OPERATOR Z/ / BILLING PARTY Y / N� DBA ^� ( PHONE #1 ( ) ADDRESS 2 p� � 8.--�f.�' PHONE #2 ( ) CITY _ �E < / STATE �� ZIP 13e APN # Land Use Application # BOS Dist Location Code A - I I CONTRACTOR and/or SERVICE REQUESTOR `✓/L �� DL �//( L� BILLING PARTY V / N DBA�Yi 5c� / I Af-9' O�w PHONE #1 FAX # 02-0R )3`,? /- 67z MAILING ADDRESS �� d 7" 12VO G G �r CITY N G STATE( � ZIP —//�a'�l` 2Z'49'5rf) BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD 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 t 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 PAYMENT Title: Date: RricraivEn AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, op�F-'"chnep-M of same, of the property located at the above site address hereby authorize the release of any and all results, geoteical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH QI.VISION as soon as It Is available and at the same time it is provided to me or my representative. iU b�10 HEALTH SERVICE: / c tNVIR _r' n, NT1 Nature of Service Request: 5,!t, Slti� Z—h� / / �y �7 � � Service Code �'- Assigned to rA_---� ✓I� Employee # 6 T Date Date Service Completed / /�_ Further Action Required: Y / PROGRAM ELEMENT L C Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By is6.6a0 I q RENS /�� SUPV _/ / ACCT UNIT CLK _/ /