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SERVICE REOUEiST (EH 00 51) Revised 8/23/93 FACILITY ID # RECORD ID # r INVOICE # -00771 FACILITY NAME n BILLING PARTY Y /nN SITE ADDRESS CITY L 0 / CA ZIP OWNER/OPERATOR _. u,/�L��/ �4 G G>EE BILLING PARTY Y / 0 i 1 DBA PHONE #1 ADDRESS (e, G�TTyssg u£ �- ,�� 4 . y PHONE #2 ff CITY Ty CAE-7v STATE CA- ZIP 47-5-2-07 7 APN # Land Use Application # IF ,�J�v p — =BCr- Di.t Location CodeC� CONTRACTOR and/or SERVICE REOUESTOR O G k E S^J BILLING PARTY Y / N DBA Qu A G- r7� (o�7`��-- �,yS,00Ec-770 1,�AfpHONe #i F MAILING ADDRESS ��+ ! s FAX # ( ) { /KopEST z ) CITY C✓ STATE A ZIP p�L 536 r BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of Same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on i Page 1 of this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN i JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. I APPLICANT'S SIGNATURE Title- Date: 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: .S O r L s u 1 TSB I L I J-ru AD Service C 2•• , 6 -pQEr.JdttM, r Assigned to O L to r. ,AA Employee # 32-1 Date 10 � q Date Service Completed to / / l 6 Further Action Required: Y ON PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By or, _ v 7� UNIT /RENS _ / v i