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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # RECORD ID # 01-6000 INVOICE # <br /> FACILITY NAME 6�"`�G Pu/'"`� BILLING PARTY / N <br /> SITE ADDRESS 64 4 w ` ' 1�elll <br /> � <br /> CITYCA zip S 2 0 3 <br /> OWNER/OPERATOR PAIKY -,t} BILLING PARTY Y / N <br /> DBA . !,D'< C 1 / PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY / �'`� STAT(A ZIP <br /> F APN # Land Use Application # <br /> BOS Dist Location Code <br /> a <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS FAX # <br /> CITY STATE ZIP <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 /> 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 tandards, State and F deral laws. P AYIVI ENT <br /> RFrIFIVFn, <br /> APPLICANT'S SIGNATURE <br /> JUN 2 2 1998 <br /> Title: Date <br /> SAN JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above when applicable, 1 the owner PUHEALTH)kES <br /> PP .ePFt9R0f ATA@Si_1VDWDW)Nof <br /> the property located at the above site address hereby authorize the r0base 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 reprdfentative. <br /> Nature of Service Request:`- Service Code o <br /> Assigned to Employee # � Date <br /> M <br /> Date Service Completed /�L/�� Further Action Required: Y / N PROGRAM ELEMENT L�J•B 6 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> °D G/z <br /> REHS 17—�/�/ SUPV / / ACCT _/ / UNIT CLK _/ � <br />