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� 1 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # V C, INVOICE <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY /'///U�GC�f�'(� CA ZIP <br /> OWNER/OPERATOR �/D /�/ BILLING PARTY Y / N <br /> DBA " J 5 k —" J DA-) C— PHONE #1 ( ) <br /> ADDRESS O PHONE #2 <br /> CITY /`��� STATE ZIP ! �/ <br /> E APN # IF and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or 8 <br /> SERVICE REQUESTOR � �� BILLING PARTY Y / N <br /> (�(/j[/J <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS P1 � O / FAX # ( ) <br /> CITY �j STATE ZIP / �.7 `7 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be;o, agcordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> ll��e� <br /> -��FrFIRrR-� <br /> APPLICANT'S SIGNATURE N O V 1 1g95 <br /> SAN JOAQUIN i UuNTY <br /> Title: Date <br /> cNVIRONMENTAL HE <br /> AIIETRuVI[;ES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, open,6W®W4kint 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. <br /> Nature of Service Request: / Service Code <br /> Assigned to 0 ( � 9 Employee # % 7 Date <br /> Date Service Completed / / Further Action Required: Y / l PROGRAM ELEMENT;9-4� ' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By s <br /> X56-°° <br /> SUPV /_J ACCT - l'l / lUo� /C/ UNIT CLK /_� <br />