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-` SERVICE REQUEST - (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID /# INVOICE # <br /> FACILITY NAME / / CJI t° SS 126, ,, -� / /� BILLING PARTY Y / <br /> SITE ADDRESS � lL'EI/Ll /J./V( L ot,,n- /AcrcAeA +/}4/Qg <br /> CITY / (ei aeI CA ZIP <br /> OWNER/OPERATOR I`-L-1 J 000(kee BILLING PARTY Y / N <br /> DBA1r � I,, / D PHONE #1 ( <br /> �/ 7 U ) <br /> ADDRESS I �1` l o ✓ l k L, ?PHONE #2 ( C b 1 ) �v 7- ( 70 C <br /> CITY STATE 1.-.H ZIP <br /> p APN # and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR "�elI I1U P�� O� BILLING PARTY Y / <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> ZIP 'PAYMENT <br /> CITY STATE L� G i C RECIP111" <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and <br /> `J7a IY�rUAVUfm <br /> e._ <br /> Iaf,JN Y <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified asP�BLBLtq�RL T EMICES <br /> Page 1 of this form. ENVIRONMENTAL HEALTH DIVISION <br /> I aLso certify that I have prepared this ication and that the work to be performed wilL be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Cod and St rds, State and Federal Laws. PAYMEW <br /> RECE11, <br /> APPLICANT'S SIGNATURE <br /> p SEP - 8 1995 <br /> Title: ��p,i— Date: 0 l( f— SAN.IOq <br /> QUiPo ,. <br /> EIIgqPUBLIC HEALTH, <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabLe, I, the owner, peAAW%E -b*1gt4l",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 avai Lable and at the same time it is provided to me or my representative. <br /> Nature of Service T*R,egquest:((''�� Service Code (� <br /> Assigned to �J ll Jc-(-N-`�-4 Employee # O -1 Date <br /> Date Service Completed l / l / c Further Action Required: Y / PROGRAM ELEMENT Z <br /> A. cf,c e (ca i d a dd 14f'-a/ 1.S6 IV 121 / [&Wfl 1-cSeCt1A/ u,4-(- /AU <br /> Fee Amount Amount o Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS / /-L / } SUPV C T�/ (7 5 ACCT _/ / UNIT CLK /�_ <br />