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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID #1 INVOICE p-� INVOICE # zLL/ FACILITY NAME y� / � �7 --I/�/�/I \ I� BILLING PARTY Y N Lv SITE ADDRESS <Z2- CITY fl/1 22e-) CA ZIP �� / ✓ jt J .7 J OWNER/OPERATORBILLING PARTY / N1 DBA <:�7 PHONE #1 1 )� -�LG/ / Z 6V2 ADDRESS �! PHONE ##2 ( ) CITY O �� STATE (�f ZIP APN # Land Use Application # IFBOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR r1i �� BILLING PARTY Y / N DBA �J Z' / f� / �< �Z L� PHONE #1 (009 )�- ` /Z- MAILING ADDRESS Z FAX it (,7L^l� ) r7 f C/ CITY A G-Ca 2, ?J�C> STATE �_ ZIP C/ J��2-U BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified_Pt,he BILLING PARTY on Page 1 of this form. e°�" I also certify that I have prepared this application and that the work to be performed will be done � t�dQnc�tllptth all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. J L)UN.�S I JAN i(jP.oU1N LJUN I i' PUBLIC HEALTH SERVI APPLICANT'S SIGNATURE EN VIR 4EP IC7LATitle: �i ��=1� ZP�j� Date: �/ 1-!5- 9� LTH DIVISION AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 same time it is provided to me or my representative. Nature of Service Request: 4 Service Code Assigned to Employee Al �0 DateJlT Date Service Completed Further Further Action Required: Y / 6 1 PELEMENT L L Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By t - -n Il- I1�6- [bbl 50- REN1 / / SUPV / / ACCT I '0 UNIT CLK / /