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SERVICE REQUEST P w (EH 00 61) Revised 8/23/93 <br /> l�/ •� INVOICE # <br /> RECORD ID # <br /> FACILITY ID # <br /> FACILITY NAME ( ( S 'ELI� BILLING PARTY Y N <br /> SITE ADDRESS �7QZ./ KoA�ELf}-N � CT <br /> CITY .S Tb CA ZIP <br /> OWNER/OPERATOR lq-(�4-3 7-7 el-) �'" 2-S BILLING PARTY Y / N <br /> DBA <br /> 15 .Sj (/c LC PHONE #1 ( fir/ ) q57 _ <br /> ADDRESS —7-7 &r-0 MO /LE L-1�'� C7- PHONE #2 <br /> CITY Sip-32I:lGTy.J STATE GqA- ZIP [ 5-2•'/ Z <br /> APN # Land Use Application # <br /> S ,4 _ q _ 33 BOS Dist Location Code 9 9 <br /> CONTRACTOR and/or LF E SSO Ge /Q-]�-S BILLING PARTY Y N <br /> SERVICE REQUESTOR <br /> ^ PHONE #1 ( -70? <br /> DBA <br /> MAILING ADDRESS 6 37 yv - lqC/DunWE"L'C— /3 LI/,� FAX # ( ) <br /> CITY P�.-TA Lu.y-t A STATE c A ZIP `TP1541 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowLedge that all site and/or project specific <br /> PHS/EHO 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 /> i also certify that I have prepared i application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes St a , State F rat laws. QAC A f � <br /> APPLICANT'S SIGNATURE �nnR <br /> Ti te: �' 0'1�1. 9— Date. Cf' 1P-` .. JJS" <br /> 1R <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: <br /> PL- 4�j GL!£cK — GALwJ/fSK Service Code SL2 <br /> /NS 7�•�1--�4''R O <br /> Assigned to G pt_tJE 1 +e.q Employee # D3 1/ Date ! 2-/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ,/f z • D <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check #G Recvvdd�BByy <br /> /SG oA /S6-� !a (L @h CKEL� �boZ 0 v <br /> RENS ! / /6 SUPV / /_ ACCT J��' /� UNIT CLK _/ /_ <br />