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SERVICE REQUES(T'} (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # O X Q INVOICE # O�,J�]J o9 FACILITY NAME U BILLING PARTY Y /� ' SITE ADDRESS -L/7 3 7�, y �. �`- 5 3 CITY ;CA ZIP ! / OWNER/OPERATOR l\ I O 4Z-7BILLING PARTY Y_U I N DBAJ�� L,C'P lv�'7 !__�+ h PHONE #1 (__) �"✓_._ ADDRESS /-�-"/ / /5 PHONE #2 ( ) p CITY r7 O 4:- ` r�A'I STATE`2IA f ZIP ' �V f 7 12 FAPN # Land Use # — (� BOS Dist Location Cade J S` CONTRACTOR end/or �+ 1 SERVICE REQUESTOR J 1 e * C d �� _ BILLING PARTY O / DBA ��j,� PHONE 41ft MAILING ADDRESS `'� VjbI�S `YJ ��"' Z�0 FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site ardor project specific PNS/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 he done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of game, of the property located at the above site address hereby authorize the release of any and all result: ate and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E HEALTH DIVISION s It is available and at the same time it is provided to me or my representative. e Nature of Service Recpuest: Assigned to 7T�-� Employee # / Date Date Service Completed _2=/ Ly Further Action Required: Y / �1 PROGRAM ELEMENT L� . Fee Amrunt Amount Paid Date of.Payment Payment Type Receipt # Check # Recvd Sy j {� I6-&.6D 1-2-11I9S ✓ fS�8 �b • REFS _/_/ SUPV _/--J_ ACCT ��/� UNIT CLK —fes_