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SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # (� 3 3 INVOICE # FACILITY NAME L-2 �/jDS [BILLING PARTY Y / N SITE ADDRESS 13 2 �_/��A IV L��l�► CITY �SCAL�[Y CA ZIP OWNER/OPERATOR S-rA M 1-30 N P5 [:BILLING PARTY Y / DBA PHONE #1 ADDRESS .2 N DS PHONE #2 ( ) CITY Sc A LON STATE `CA, ZIP APN # Land Use Application # BOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR Dom C�K�SI�+�I� _c [BILLING PARTY T� / N DBA QUALl7� CUN(R-OL J 0 r � r(ON/ PHONE #1 ( ) TY? - 9 77 MAILING ADDRESS 1 S� N- 9 M Gam` FAX # CITY / \(�Z��S� STATE ZIP��3.S^� BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site ar1"�)}��iecific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BALLING PARTY on Page 1 of this form. NOV 2 5 199/ I also certify that I have prepared this application and that the work to be performed will be done in acc�rkg8i6aheiJli" Eg. JOAQUIN COUNTY Ordinance Codes and andards S t and Federal laws. PUBLIC HEALTH ENVIRONMENTAL HEALTM DIVISION 61&APPLICANT'S SIGNATURE ay / Title: V . P _ Date: /I 7 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: Service Code r� Assigned to Employee # C) G 1�) I Date ,i Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS C. /�/Z S SUPV _/_/ ACCT _/ / UNIT CLK / /