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• SERVICE REQUEST (SERVREQ) Revised 5/13/43 FACILITY ID RECORD ID # Egq, BILLING PARTY Y N • FACILITY NAME �W/ ( l�I��1J� c-T70KS Cl tC-� �y � All J � i SITE ADDRESS a� 4— L�IF �P CITY CA Z I P OWNER/OPERATOR T IJ�ryVTT� Ca�ETI� BILLING PARTY Y / N DBA PHONE #1 ) - ADDRESS � ) q& Z#a7> CITY STATE ZIP APN # Census --------- SOS Dist Location Code City Code -- -- fCONTACT /or SERVICE REQUESTOR =BILLINGPARTY Y / N DBA Q� PHONE #1 MAILING ADDRESS . ©r— O FAX # CITY STATE ZIP �U l • BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as :he BILLING PARTY on Page 1 of this form. pq�/��±�� I also certify that I ha repared application and that the work to be perforff i!U>l��in accordance with all SAN JOAQUIN COUNTY Ordinance od nd Sa dar to Federal laws. RECEIVED APPLICANT'S SIGNATURE 0 C T 0 4 1994 JOAQ Title: G== Date• PUBLIC HFA! ION AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: `��/ �K ��f �� Service Code 1 4� Assigned to � � � Employee # ? fo Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ' p Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/_ SUPV• _/ / ACCT _/_�_ UNIT CLK