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SERVICE REQUEST l7/ 1 "�RaA1 A1423/73 FACILITY ID N RECORD ID N T"N a ala FACILITY NAME SITE ADDRESS S CITY / VVNFR/OPERATOR DBA ADDRESS CITY r—APN N FACBILLING PRRTY Y ( N INV ti CA ZIP 51'y 5� STATE Land Use Appi l cat i on N = ZIP KILLING PARTY Y / N PHONE N1 ( ) PHONE N2 (_)— ZIP ) ROS Dist Location Code CONTRACTOR and/or Amount Paid Date of Payment Payment Type Receipt N Check N.. SFRVICE REOUESTOR //(G� BILLING PARTY �- DBA S r/'T' _ PHONE 01 ( ) MAILING ADDRESS / • D, A �©Py- �j FAX N ( ) CITY (/ G� (/( / -STAT ZIP �� BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on FI 1 of this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sank, of 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 sane time it is provided to me or my representative. Nature of Service Request: i[/(/ e'•G ` Assigned to Dote Service Completed / / CLliJ �Q(.6101'.[ Employee N Further Action Required: Service Code Date —/—/ Y / N 1 PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N.. Recvd By REHS 4/ Z' /z//— I SUPV _/__/_ ACCT _// UNIT CLK _/ /_