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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # �j� I INVOICE # 17 .�' V ' <br /> FACILITY NAME �p/CI'✓ 7 Y nl�L�� l��� BILLING PARTY Y / <br /> SITE ADDRESS �`' L/ . �bu/Se /'7 ✓'� 3 <br /> CITY f--1�S�/7 CA ZIP <br /> 1. <br /> OWNER/OPERATOR l){,y • (',.PARTY Y '�'�11 <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) - <br /> CITY STATE ZIP <br /> FAPN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ��j�../A/// �` ��-S� �/ BILLING PARTY / N <br /> DBA / PHONE #1 ( ) <br /> MAILING ADDRESS J t--�O/�f-'/ )x/.-v>/ r FAX ## <br /> CITY �/ �L � STATE �1%` ZIP Z7`� Zn / <br /> BILLING ACKNOWLEDGEMENT: I, 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes d Standards, State and Federal laws. <br /> cam) - PAYMENT <br /> APPLICANT'S SIGNATURE 4ECED/En <br /> Title: ,/J / Date: /% 9�5 JUL 71995 <br /> SAN JOAOUIN GJU <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operatoPldBf OPEAt ICES <br /> the property located at the above site address hereby authorize the release of any and aLl resuLts,rgevfftWQ"-W'&ANTdwt{i{9"DIVISION <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: /' Service Code q C <br /> Assigned to \ JOLp-V�.I; Employee # ri ,[fib Date —7 -7 <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> s �s -7 (q5- Ghpcli� I L) <br /> REHS / / SUPV _/ /_ ACCT _/ / u' UNIT <br />