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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # b(0 ' INVOICE # <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP , <br /> OWNER/OPERATOR �- ' YrlwA- C'EG�j C�'/f/l i <rs/L BILLING PARTY / N <br /> r �y <br /> DBA PHONE #1 ('7/lv ) 77.3 <br /> ADDRESS 5D L�i►r✓L3F� E % SSC // PHONE #2 <br /> CITY < --I///Xt' STATE 9-4 ZIP 2-S& 7Ji <br /> F APN # and Use Application # <br /> BOS Dist Location Code <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: 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 /> 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 Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 /> 11- <br /> Nature of Sewer e -Q Service Code <br /> Assigned to ������A-J Employee # 92 Date <br /> D� 29 �lO <br /> Date Service Completed / / Further Action Required: Y / � PROGRAM ELEMENT �• �Li <br /> Fee mount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 6C� L <br /> /..3� <br /> REHS —/ �� / SUPV / / ACCT �/ �/ / UNIT CLK / / <br />