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w. SERVICE REQUEST S 0.E0) Revlsed 8/21/91 fACILI TY ID N //� .� RECORD Ib N ', IAvo10E N fACILITY NAME RC,/6 7A Y / N SITE ADDRESS CITY CA ZIP �5 z3G OWIFR/OPERATOR SSG —z BILLING PARTY Y N ORA PHONE NI ( ) ADDRESS PHONE 02 ( ) CITY STATE 21P —APN N —Lend Use Application M IbOS Dlet Location Code CONTRACTOR and/or SFRVICE REDUESTOR BILLING PARTY Y // N DBA /Ti'.KJ/ne m ,( �.i ,p s'�.�.- ._sL T PHONE NI (24;`' ) /Y6f - �� MAILING ADDRESS �U�l ��<+[�-�i--9/oma- O.C�oc, fAl( N ( z ) CITY 's 7U�-6, l f7^— STATE 21P RII.LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PIIS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Page t of this form. I nlso certify that 1 have prepared this spplscation and that the work to be performed will be done In accordance with all SAN JOAOUIN COUNTY Ordinance Codes and Standards, State end Fede al lows. APPLICANT'S SIGNATURE ?z/ Title: .F --rrr" /? a-- Date 7-22 AUTHORIZATION TO RELEASE INFORMATION: In additl on to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envlrormental/site assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is available and at the same time it 12 provided to me or my representative. Nature of Service Request! L( �2tti�LL-/�¢../i Service Code ic Assigned to R`�W.0—zil d Z, Employee N Date / / Date Service completed _/_/_ Further Action Required-! Y / N PROGRAM ELEMENT3— Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By AS _ RE — f NS / / SUPV / / ACCT / / UNIT CLK / /