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ifll) 5 c7-�f— // SERVICE REQUEST — (SERVREQ) Revised 8/23/93 FACILITY ID / I I RECORD ID IF L INVOICE / f FACILITY NAME J6 .EMTY Y / N S11E ADDRESS ' n j� CITY - CA ZIP li tf - f?WNFR/OPERATOR �GTO/--P /' BILLING PARTY Y / DBA PHONE M1 ( ) ADDRESS Z 383 � �/ ✓ ` PHONE 022 ( ) CITY " Com'P"Yl �lJ .JJ STATE <'71A ZIP C752 -2-02 T NAPM R — =Lord Use Application K I ) 4' 174-11 SOS Dist Location code SERVICE OR and/or /" SERVICE REOUESTOR !!/'� /J�7� 7 �_ BILLING PARTY � �/'-�Y / N ORA CJ2/� / C `��7��J�'�j PHONE 01 (7c_l)�L,' O y MAILING ADDRESS -/ /! 2 '^� � — " G� FAX It city -« fvI /lam STATE ZIP / PILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of a", acknowledge that ell site end/or project specific PNS/EHO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Peg:1 of this form. 1 also certify that 1 have prepared this application find that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes aanddSStandards, State and federal lows. APPLICANT'S SIGNATURE Title: ceSI% !- /> / / �,/;LIQ-� Date- AUTHORIZATION 70 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 and sit results, geotechnical data and/or environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It is available and at the some time It Is provided to me or my representative. Nature of Service R/e�quest:_�-.o"e r i� Service Code Assigned to /C�[/ ��iCg � Enployee M �� ' / Date Date Service Completed _/ / Further Action Required- Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By BF XS I / / SUPY _/_/_ I ACCT _/_/_ UNI 1''CLK _/ /_