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SERVICE REQUEST (SERVREQ) Revised 8/23/93 i FACILITY ID # RECORD ID #10 0 San a__. INVOICE # FACILITY NAME BILLING PARTY / N SITE ADDRESS CITY CA ZIP L � B LLING PARTY Y / f OWNER/OPERATOR V�' v� I 1 DBA PHONE #1 (Pft-) ! - E! ADDRESS '7L6^/ T PHONE #2 ( ) CITY CO"/ STATE CR zip 3 ZO [APIN # land Use Application # 20� _r2 Dist Lotion code CONTRACTOR and/or Q ��Q`c�yfu�I a/ {"fOl, i�/C, Bill PARTY Y I N SFRyIrsF 9SAliE814R lr PHONE #1 �7� DBA r� �L� ��/STl/�./ [��..1, # { 7irl'f ) 3�� - �3• MAILING ADDRESS (/ FAX CITY STATE 4 -- ZIP '9S 2 -to acknowledge � acknowledge that all site and/or project specific BILLING ACKNOWLEDGEMENT- I, the undersigned owner, operator or agent of same, PHS/EMD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and andards, State and Federal Laws. APPLICANT'S SIGNATURE ' Title: / Date. /2 /�A ` AUTHORIZATION TO RELEASE INFORMATION: In addition 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 environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code Assigned to G Employee # Date J--/--L-7 / q Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z � Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS / / SUPV �/ / ACCT /M./(4 UNIT CLK _/ /