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• � °"'` SERVICE REQUEST {EN 00 61} Revised 8/23/93 FACILITY ID # RECORD ID # INVOICE # FOt f 73 FACILITY NAME 77 (( BILLING PARTY Y / N SITE ADDRESS �I L C f e r {� CITY Grk p CA ZIP OWNER/OPERATOR }yV 06 r I BILLING PARTY Y / N DBA - ��_, Y� i K i S 1 - _ PHONE #1 ( ) ADDRESS lJ ! / PHONE #2 (-) 347- CITY (-CITY L� � _ _ STATE ZIP JS K � e? _ APN # and Use Application # � 805 Dist Location Code CONTRACTOR and/or /y r SERVICE REQUESTOR Sr p 1 m C-- 1� Yea U 2 _ PAYMENBILLING PARTY Y / N DBA RECEIVE RR5)NE #1 . ( ) IJw MAILING ADDRESS SAN JOAO(I!Nr;0;; &'# ( _ PUBLIC Ir:RVICES CITY STATE ENVIRQN�PTA� HLALTH CSM' IQN 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 thiplication and that the work to be performed will be done in acPAa�I�all SAN JOAQUIN COUNTY Ordinance Codes and Sta;-,,ds, State and Federal laws. RECEIVE APPLICANT'S SIGNATURE : M A Y Title: Date: XSAN JOAQUIN COUNTY HEALTH SERVIICESeL AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner,N open torEor agent o Ts.RJy1§#ON the property located at the above site address hereby authorize the release of any and all 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 same time it is provided to me or my representative. Nature of Service Request: s,4 LZtAL Service Code (9 Assigned to �$�--�q mployee # D`�� t Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By SUPV �/ / ACCT 5-1 -101 UNIT CLK U