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All SERVICE REQUEST iEH 61) Revised 8/23/93 FACILITY ID # RECORD ID # INVOICE # 0 6 FACILITY NAME Z E7J T2-4-IL donz-ePZ i7- BILLING PARTY Y / N SITE ADDRESS --Z07-6-3 1,�JQ. Gff-*7-77-c L �ii11 CITY CA ZIP OWNER/OPERATOR J_J��+ ItI`r� yF�I]�� BILLING PARTY / N / DBA PHONE #1 ( _) - o y6 ADDRESS /_L.3 1 6 L-M6-1—c PHONE #2 ( ) CITY 4-00 J STATE C-A ZIP ��X10 APN # and Use Application # 1E m s - 9 6 - I-I ::1 BOS Dist Location Code CONTRACTOR and/or - SERVICE REQUESTOR I��/'V L� o6ZytomNBILLING PARTY Y / N ' DBA S7-F-L opts/ L S PHONE #1 ( Zag )'N8 - 13 NS MAILING ADDRESS X825 E. 1V1y2-TZLr FAX # ge - a6 ZI CITY 5M li l-T-D7`I STATE ZIP 2-0S BILLING ACKNOWLEDGEMENT: I, 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 I have prepared this application and that the work to be performed will be done in accordance with ell SAN JOAQUIN COUNTY Ordinance Codes a Standards, and Federal laws. PAYMENT RECEIVE APPLICANT'S SIGNATURE G OUT 6 Title: J`I�S�� Date- .�HIY fJ�iJf1�pp} �+y!QOU i . �UB4��.��M Zj 5 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner,p Paton or ageJ%f �y=cEoi r the property located at the above site address hereby authorize the release of any and aLL results,geotechnical dat T>91A7&JJ31ON 4 environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as. it is available and at the same time it is provided to me or my representative. Nature of Service Request: [ •1 i Service Code Assigned to � [ Employee # r �� Date / / b r- Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT P' FeeAmountAmou Paid Date of Payment Payment T Receipt # Check # Recvd By RENS _/ / SUPV /____� ACCTl 'UNIT CLK _% f