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1 .. <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # C INVOICE # <br /> FACILITY NAME �}d _ r�f�7Z� BILLING PARTY Y / N <br /> SITE ADDRESS( /U� / /42J 7-. <br /> CITY CA:f T6/V CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # p Land Use Application # <br /> FI BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR 1� t CJ(1 i 5 co a` �U . N L. BILLING PARTY 17y= <br /> DBA PHONE #1 ( 5 U <br /> MAILING ADDRESS ULA COtq r FAX # <br /> CITY 1#"/E W 1-3V/� V / "'Q IG STATE CA ZIP Z3/o <br /> Dzc� �E�4E� <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 /> 1 also certify that I have prepared this application and that the work to be performed will be do accordance with DN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. MAY 2 2 1996 <br /> APPLICANT'S SIGNATURE ENVIR P441iNTAL HFAI TH <br /> PERMIT/SERVICES <br /> Title: Z��—V��`� Date: "�2 <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 /> Nature of Service Request: Service Code <br /> Assigned to 7l -�� Employee # ')&U Date _ / 2 / !E:,4 <br /> 7; <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2 zlj <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -2 <br /> RENS _ i(�uy—p-r <br /> S /—,2-z—/ <br /> Z/ ACCT /G 773/ UNIT CLK _/ / <br />