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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # RECORD ID # — INVOICE # a?, <br /> FACILITY NAME C� BILLING PARTY Y / <br /> SITE ADDRESS 9 (. / <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # F and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or / <br /> SERVICE REQUESTOR a e S + h ry�/Yii.Y�(/ =BILLING PARTY C/ N <br /> DBA PHONE #1 <br /> MAILING ADDRESS l vl v / �// Cr FAX # <br /> CITY CaA-Ijo STATE ZIP PAYMENT <br /> 1l �T <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that allLStie a�rj$ ct specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as 7 BILLING PARTY on <br /> Page 1 of this form. SAN JL)AOUIN GUUfv1 Y <br /> �/+PcU�fBvLIICE HEALTH SERVICES <br /> I also certify that I have prepared this application and that the work to be performed wi&N4Rdo'r qkT, �'A&jFLP&IAPr4AN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State 9nd Federal taws. �Jp <br /> APPLICANT'S SIGNATURE 1— IL / Otv <br /> Title: l/�`�I� Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of 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 available and at the same time it is provided to me or my representative. �y <br /> �'/ S({%� �J /"/ �a`�tG� y "�( C L -b Service Code �a <br /> Nature of Service Request: Ircy,C w T a <br /> Al", Y/CnS� <br /> Assigned to (fd AltvC/ � Employee # �6`/ Date /o / <br /> Date Service Completed / / Further Action Required: Y / ( PROGRAM ELEMENT �7 , <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT UNIT CLK <br /> v' <br />