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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> -T <br /> FACILITY ID # D # INVOICE # ) �/� <br /> �ECORD <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS __ ✓� zL. ;� Zr k� <br /> CITY 710-L CA ZIP <br /> OWNER/OPERATOR G' 0 M I� 6 BILLING PARTY Y / N <br /> ��/� n <br /> DBA hVI I ll ,� r r T l� PHONE #1 <br /> ADDRESS ��1Z01 's-t�+z I PHONE #2 (•4U`� ) 11.�.� - 279 1 <br /> CITY I 1^�1 Cl STATE ZIP <br /> FPMA # Land Use Application # <br /> 2�s Tt c— (4(C S " 1-)�5 - aCI BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTORBILLIN <br /> ��}LY� �c G PARTY Y / N <br /> DBA I V L� l C1• C -X �'1 `� PHONE 01 (-)-Cel ) Z- 3-70 <br /> MAILING ADDRESSL_ �1 "��,1 j S J�� �r(� 1 FAX # ( (, () 3 3 - -%-3 <br /> CITY ( _� STATEk 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 /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and ndards, State and Federal laws. <br /> APPLICANT'S SIGNATURE : / O <br /> Title: / Date:- /d g <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 /> envirormental/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 <br /> }-} <br /> Assigned to x co Employee # Date <br /> Date Service Completed -/-/ Further Action Required: Y / N PROGRAM ELEMENT 7 (o ,-Z- Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> F <br /> SUPV _/ / ACCT / I ! 1 /(j I �i UNIT CLK _/ / <br /> ���`� —T <br />