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SERVICE REQUEST (SERVR£G) Revised 5/13/93 <br /> E <br /> 1L i0 # <br /> RECORD 10 # BILLING PARTY Y / N <br /> FACILITY NAME <br /> + SITE DRESS U/ <br /> CITY 1 CA ZIP <br /> OWNER/OPERATOR ` Y i / 7 Z- Q BILLING PARTY Y I N <br /> DBA ( PHONE 91 ( ) <br /> ADDRESS iWop <br /> PHONE 92 <br /> CITY � � STATE ZIP O <br /> APN # Census BOS Dist Location Code City Code ----- C/� <br /> <CC TNOTRRACT /or <br /> SERVICE REQUESTOR , �J�GQ Ls�(� 't Q��Q =BILLING PARTY Y / N <br /> DSA PHONE 91 ( ) <br /> MAILING ADDRESS FAX <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD 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 done in accordance with all SAN / <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: 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. <br /> n <br /> Nature of Service Request: _7-7 ��� Service Code: SR.0610 2 3 y <br /> Assigned to Employee #: Date: <br /> Date Service Completed: Further Action Required: <br /> PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 00 <br /> RENS __/ / SUPV _/_f ACCT _/_� UNIT CLK _/_/ <br />