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SERVICE REQUEST (SERVREQ) Revised 5/13/93 FACILITY ID # �I RECORD ID # BILLING PARTY Y / N FACILITY NAME 75 SITE ADDRESS GUT ELT'IEV— R6Fin CITY AcAmc G2,z®('2 ® A CA ZIP 95 2,z (-2c>�) 3b 1 S --97—/ O OWNER/OPERATOR BILLING PARTY Y J EA DBA PHONE 01 ( ) ADDRESS PHONE #2 CITY STATE ZIP APN # Census --------- BOS Dist Location Code City Code - -- - CONTRACTOR and/or SERVICE REQUESTOR VYAt_TP f CI LIILLING PARTY Y� / N DBA i PHONE #1 ( ) MAILING ADDRESS 4-IF3 MA,=+-ITYY J�L�AZA FAX # ( ) CITY k-oT- STATE �•. ZIP �rj24� BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific CHS/EHD 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 Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: C�Yi L_ Dater 493 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 some time it is provided to me or my representative. Nature of Service Request: �C wRT1�Y�1 T=ST Service Code: Assigned to :_ Employee #: Date: Date Service Completed: Further Action Required: PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS _/ / SUPV �/ /� / 927 ACCT _/ / UNIT CLK _/�