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SERVICE <br /> /REQUEST (E4 00 61) Revised 81 <br /> FACILITY ID # r ,_w RECORD ID/#7 ^L�J1/,�1 /a `l :NVOICE <br /> FACILITY NAME 7/-7f-k�� IA—IOS N AT C ?LI /41 'T/yY BILLING PARTY q Y / N <br /> SITE ADDRESS (L 3 D F-/ZEy Er`T Q/ ) cto/n,✓` I 1 <br /> r.'s , q�z� <br /> clrr STJOII' I <br /> .ILTD/VII� CA ZIPP <br /> OWNER/OPERATOR /L /L f7IAk! b ITA4/yo BILLING PARTY Y / N <br /> DBA _-S?rAC NO S /MEAT ` [/ PHONE #1 C ) <br /> ADDRESS P. <br /> 0- Bok J? / PHONE #L C ) <br /> CITY ?�--5CAI ON STATE eA ZIP C� <br /> APN # Land Use Application <br /> F # <br /> D <br /> /� p4 _// BOB Dist Location Code <br /> CONTRACTOR and/or C (� 7 [�. <br /> SERVICE REQUESTOR ofq GNcINE�/ BILLING PARTY G / 4 <br /> DBA U��A /CGSCI'C�f'I PHONE 91 C )f1z - Lae, <br /> MAILING ADDRESS J'• O - /0^0 A :37-74 FAX # <br /> CITY r,d2LOG1K- STATE -CA— ZIP 5T3 / <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this fora. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accdrdanFe,wi"LL SAN <br /> JOAQUIN COUNTY Ordinance Codes standards to and Federal Laws. <br /> APPLICANT'S SIGNATURE r R 1998 <br /> ' Jnf10N <br /> CES <br /> Title: Date:/ /7�g , kyle, <br /> ��N�.� _ _I i;,A_HEALTH OiV1S <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sane, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. L` C� <br /> Nature of Service Request: <br /> w'eL✓ Service Code ✓ �J <br /> Assigned to p, z ^/Y �iEmployee # C:' v Date —/—/ <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT = "Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check Recvd By <br /> ✓ <br /> REHS _/ /_ SUPV _/_/_ ACCT _/ /_ UNIT CLK _/_/_ <br />