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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # (/1 INVOICE JSi��> <br /> FACILITY NAME Q G j G 9 BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY / Y ) / N <br /> DBA HONE #1 ( �.' <br /> ADDRESS-3 7Y ,L 3 a (0 PHONE #2 ( ) <br /> CITY G C-1 STATE C,,) _ ZIP ` / (0 J <br /> APN # Land Use Application #IF <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR S>Z>��y )�/ 2 BILLING PARTY Y / N <br /> DBA �'!/)�`f2i �= oL V ~ I—�2—.-- YAG PHONE #1 ( ) <br /> MAILING ADDRESS a2 5 Lr1.�' l �/ cf�� FAX # <br /> CITY /—(/ i STATE ZIP �✓� �G <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD 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 I have prepared this application and that the work to be performed will be done in acc0�ilance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. (7 <br /> MAY 14 1996 <br /> APPLICANT'S SIGNATURE <br /> JOAQUIN <br /> �U$LIC HE _' , <br /> Title: Date: -lVuroSERVICES <br /> TAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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: 4/ Service Code <br /> Assigned to �Q� /l� GY ✓� 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 G �I1 / SUPV _/ / ACCT UNIT <br />