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.ry SERVICE REQUEST y. (EN 00 61) Revised 8/23/93 <br /> FACILITY ID # / RECORD ID # se, Db <br /> /'�— , INVOICE # Da/7�y <br /> FACILITY NAME le. Pe�/ e1LLI NG PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> C ppN # P Land Use AppLicati on # BOS Dist Location Code <br /> CONTRACTOR and/or �L� I /p <br /> fb <br /> SERVICE REQUESTOR SUUQ.,[,F'1 _ BILLING PARTY / N <br /> DRA I/IN ��IpL/�� �t14(�bv �j� PHONE #1 (510 ) QZ'51 - W& <br /> MAILING ADDRESS ti'\te�l ����(`-'rpl dwW, CS j�� I X0//11�1 ��//�� FAX # (5(o ) ""3 _ ?ZO5 <br /> CITY L/�,lA 1 STATE lam^ ZIP ✓`r <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /Coojddee/yss and Standards, State`ann�d FFeecleer�atLaws. <br /> APPLICANT'S SIGNATURE : "y',^�"� //�x /rL(/ J. S `^"�'y / <br /> Title: I)(.titj— Date: 61z l05 <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. n <br /> Nature of Service Request: r 'e Service Code Cl <br /> Assigned to 0- Enployee # / Date <br /> Date Service Completed ( / Further Action Required: Y / N PROGRAM ELEMENT a / (JV <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> l <br /> REHS _/ / _` SUPV _/_/_ ACCT i JL&/ L /[�_ UNIT CLK _/_/_ <br /> IV <br /> /( <br />