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SERVICE REQUEST �+ (EH 00 61: Revised 8/23/93 <br /> p FACILITY ID if / C RECORD 10 # ( ® I� § INVOICE # �J <br /> F FACILITY NAME! .�L <br /> Soo-7Y sss BILLING PARTY Y / N t <br /> SITE ADDRESS /Uld & ( Y( f c :/( t <br /> CITY ~—� �7 CA ZIP <br /> OWNER/OPERATOR BI LLINS PARTY "�� / N <br /> DBA /� 12— C9 P!IQNE 41 <br /> ADDRESS Z40-�/ DA�Z .��/rJ/I/ Z40- PHONE #Z <br /> n <br /> CITY N �/y-tJt— C' STATE , ZIP <br /> �APNLan <br /> # - - d Use Application it - - - <br /> BOS Dist I i Location Code I <br /> CONTRACTOR and/or <br /> SERVICE R'cQUESTOR NE/L O. lIn60�2Jtr�Y • /�TJ�c T.sc . BILLING PARTY 9 Y / N <br /> 99 P <br /> DBA PHONE- #1 (2C, )JC 7 - 7701 <br /> MAILING ADDRESS 22 h/. A*-.rrVN f,A4 rAK # ( ) <br /> CITY I CJF STATE ZIP 9JrZ C O <br /> _ Acp�y�"MFN///��r,,, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator c,r agent of same, acknowledge that ell, site arevroject ific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as t e BILL,IG'91L3T�Y on <br /> Page 1 of this form. ``����U <br /> PU AN vOqu <br /> ENVlgpNVO FIfA�rN Cpu <br /> I also certify that I have prepared this application and that the work to be performed will be d In accoSSAN <br /> JOAQUIN COUNTY Ordinance Codes d Standards, State and de laws. GLrH OIVIS10A <br /> c <br /> APPLICANT'S SIGNATURE ��-- <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, 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. <br /> Nature of Service Request: ( I CAS a Code 2� <br /> !�L Assigned to :yAWL& Q G��'1 ;Further <br /> mp yes # l (- Date <br /> G Date Service Completed / Z$ / `V Action Required: Y / PROGRAM ELEMENTJ�_ 4 <br /> Fee Amount Amount Paid Dateof Payment I Payment Type Receipt # Check # I Recvd By i <br /> REHs0 <br /> 0/ Z /ftI suPv _/_� nccr _J /_ UNIT CLK <br />