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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME SD �\ FILLING PARTY Y / <br /> SITE ADDRESS M61S21I)'E AVE <br /> CITY A A 1 .0 //tt�� CrA� ZIP - / <br /> OWNER/OPERATOR UA L 1TV WN TROL ��SI ECTjCA BILLING PARTY Y / <br /> DBA PHONE #1 ( )S�7 - 494a <br /> ADDRESS 1 11!� Al. EMOAALP /� C� PHONE #2 ( ) <br /> CITY In DrSTo STATE CA ZIP <br /> APN # d Use Application # <br /> �9 Land <br /> r /� 805 Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR G� l.-�� BILLING PARTY / N <br /> DBA /1 e) N ` - 4 4U_NEx <br /> PHONE #1 ( ) <br /> MAILING ADDRESS I �( S ���KFLJ� FAX # ( ) <br /> CITY C1��S�`� STATE ---(fA ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed wi(ylbep in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes Standards to and Federal laws. <br /> t:/,rJ(-; <br /> s HUI y p0 <br /> APPLICANT'S SI NATURE "/V V/pliPA I AO <br /> NTERV/ <br /> Title: Date: Q H A(I}fr,ES <br /> OP. <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: Service Code t _ <br /> Assigned to / Employee # Date <br /> Date Service Completed / /� Further Action Required: Y / PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS �, .+_Z/ ��- SUPV _/ /_ ACCT _/ /_ UNIT CLK _/ /_ <br />