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0 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> • � A BILLING PARTY <br /> ny / N <br /> FACILITY NAME <br /> SITE ADDRESS `� �L3-' <br /> • CITY CTTD�� CA ZIP G �-� <br /> rOW,NE PERATOR ��[�1.� ��J� BILLING PARTY Y �IN <br /> PHONE #1 ( � l)g�3" �� <br /> DBA <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR nd/ory- <br /> SERVICE REQUESTO115 l�CU � --�[ 1 ��]( -cif-✓�� BILLING PARTY Y N <br /> PHONE #1 ( ) <br /> DBA <br /> MAILING ADDRESS �C-�U FAX <br /> CIT aL_�l—�� -TO V STAT6� Tt ZIP <br /> • <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. PA <br /> ication and that the work to be performed will be donl9 with all SAN <br /> I also certify that I hav -�� <br /> JOADUIN COUNTY Ordinanc C nd St a s State aTtrf federal laws. S�p <br /> 1 799 <br /> APPLICANT'S SIGNATURE <br /> CNV lR�, NT�CPH S �NTY <br /> Title �8 a Date �(TNVIVS/ !, <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agen •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. l <br /> Service ode <br /> Nature of Service Request: �P H Ct <br /> Assigned to Employee # Date _/__�__/ <br /> Date Service Completed Further Action Required: Y U 3 <br /> / N PROGRAM ELEMENT <br /> _ ..q �• � 4 x n L1 . ''�1�K . <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS �'I/�!/� SUPV _/ �/ e W=. <br /> UNIT CLK _/ / <br />