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�r SERVICE REQUEST (Eli OO 61) Revised 8/23/93 <br /> ¢ FACILITY ID # RECORD Id # I FTuk <br /> I <br /> R, NVOIC_ 1 <br /> FACILITY NAME e BILLING PARTY � Y / O <br /> SITE ADDRESS _ — 5 © ___l(Y1_ �Qi2 • __ <br /> CITY l l(J � CA ZI!'_ <br /> OWNER/OPERATOR 1I JA &A Yfi 5—Sl _ ____ _ BILLING PARTY / N A <br /> DBA lam- —6kc-�j— VI�Y1 ___ PHONE #1 ( ) <br /> ADDRESS 1 1�/I LQ l� _ P!iONE HN2 ( ) <br /> CITY ��J 1l/(ii�, STATE r.,� ZIP <br /> APN # F=Land Use Application tt <br /> BOS Dist I Location Code <br /> h <br /> Y -�3g I i <br /> CONTRACTOR and/or --_� <br /> SERVICE REQUESTOR _ Ke. 0 y\, __ BILLING PARTY d Y <br /> D3A PHONE w ( C� ) - �U <br /> MAILING ADDRESS 2-2- �UIS 1 dY� �P _c F t (d`v r_> 5�P3 <br /> CITY LM I STATE ZIP J z�V <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all siteRAY Tt specific <br /> PHS/EHO hourly charges associated with this facility or activity witL be billed to the party identified OWWOnIVEIMIMPARTY on <br /> Page 1 of this form. <br /> DEC 0 41998 <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> SAN JOAOUIN COUNTY <br /> JOAQUIN COUNTY Ordinance s and Stan rds, State and Fecierr,l Laws. ENVIRONMENTALPUBLIC HEALTH <br /> S,-R ICESION <br /> DIVI <br /> APPLICANT'S SIGNATURE <br /> Titte: 4Date: Q ZPAYMENT <br /> R GF@'1/ED <br /> AUTi1ORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or ag off e, of <br /> the property located at the above site address hereby authorize the release of any and atL results, geotJAM- a@e► /or <br /> environmental/site assessment information to SAN JOAQ'UIN 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. SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Nature of Service Request: J u' V-fvService Code <br /> � � <br /> P.ssigned to Eraloyee Oate2 <br /> i <br /> Cn- <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEt4ENT�� Q <br /> Fee Amount Amount Paid { Date of Payment Payment Type Receipt # Check k { Recvd By <br /> i ' ! <br /> 1570. 00 ' �1�51�19 s ✓ " OdDS'f$� i (;b <br /> RENS I I—/ J / i SL'PV —/— -/-- ACCT I —/--/--- <br /> UKIT <br />