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SERVICE REQUEST S (SERVREQ) Revised 8/23/93 <br /> T-ACILITY ID N RECORD ID N INVOICE N <br /> rAr,IL1tY NAME ��e L� sILLiNO PARTY Y / N <br /> SITE ADDRESS <br /> CI TT S-fo Kinn _ CA ZIP CI Sz�o I <br /> rnnlrR/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE NI ( ) <br /> ADDRESSPHONE N2 ( ) <br /> CITY STATE ZIP <br /> ArN N Land Use Application N <br /> 3 c(- <br /> I5 L_ O ( BOS Dlst p T <br /> ocation C <br /> - ode �j I <br /> IF — <br /> CoNTRACIOR And/or <br /> SERVICE RFOUESTOR Cg,� G/IIJ WltincT��r�r,��' 'h G' BILLING PARTY C-Y]/ N <br /> PHONE NI (310 )532- -41-500 <br /> DBA <br /> HAILING ADDRESS ZO�ZS e) "9- vP^m,-4- �"-- FAX N (731 O <br /> CITY Torl'>~hc` STATE ZIP 10502- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page'I 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 rederal lows. //A�- 'q - <br /> APPLICANT'S SIGNATURE 4 P9r�/� ( r � ;4r[Gh <br /> Title: Pr• Date! <br /> �— <br /> A111110RIZATION To RELEASE INrORMATION: In addition to the above, when applicable, 1, 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: J Txz> 5 Service Code <br /> Assigned to �ni L:jej!-�9 Employee N Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> ree Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> 2�� 23L4 -2Gc � �� ak <br /> (Oso <br /> / / SUPV ^/ / ACCT _/_ J LINO= J/ / <br />