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SERVICE REQUEST CEH 00'61)LRevised 8/Z3/93`` <br /> FACILITY tD #: RECORD ID # INVOICE # , <br /> r _ , <br /> FACILITY•NAMEICs :i}' 1 .` <br /> . FBI LLING.PARTY;' .:•;•Y•-:' /. '.H <br /> SITE ADDRESS <br /> CITY Sod: - F1 CA zip 15SZa9 , <br /> OWNER/OP (U SCS '{ i�c� "nl.l e� BILLING PARTY Y• / N <br /> _DBA Glizclll F-� PHONE #1 (�}5�.`- . (4a <br /> ADDRESS t1P �c�WA�i' PHONE 02 ( r <br /> CITY. S�AGI�Hr:5A 10 STATE. C ZIP CAS��. - <br /> APN # Land Use.Applicetion-#-' <br /> ,BOS Dist Location Code <br /> 111. -;. .._...:: ••lll'; . <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR. C hi tS_ \J l L. � Y \ BILLING.PARTY � <br /> DBA_�13�!'t��b�IZ• `•L��'L`Y7�' ' •i -x. r:� - :PHONE #1 (.- )I_h,_• �3 � • <br /> HAILING'ADDRESS. �6 �1J -AV`'G• ' = "F--_ #. ^�Cp' � <br /> FAX <br /> ( )« <br /> .• {/.fir <br /> :. <br /> CITY, �Nj L� !STATE ' ZIP <br /> BILLING ACKNOWLEDGEMENT:1..1;_the urdersigned_owner; operator or agent'of sarae, acknowledge that all,site and/or 061&t spoeffIt <br /> PHS/EHD.hourly:eharges"associated.with-this.focility or..activity will..be:bi.lied to.the party,identifiad`as.the BILLING PARTY on'' <br /> Page 1 of this form f s: t� -:ate ': <br /> I also certifyFthat I have prepared this application and that the:work to be performed willrbe done in ance with all SAN <br /> JOAQUIN COMM. Ordinance Codes S rds;• State' F t_Laws �'`�' <br /> of <br /> APPLICANTS SIGNATURE '`' _ _ � `� �_�° <br /> `"''' `w'�� [!.:%'s'•: 'iYt;. _ - -1 f r_ I' .t:f 'r }x� .i'� <br /> VI <br /> Title. <br /> • •u `.;i.�'.":; &, Ute. f�� , ' t i, - <br /> AUTHORIZATION TO RELEASE INFORMATION. In addition to the above,.when applicable; 1, the oia�er,Nvope7o�, �game, of <br /> the property.locate .'st.the above site.address hereby'authorize'the release of. and alt;results, geotechnICal <br /> environmental/site assessment. <br /> information to.SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION--as Goan as <br /> It is.avaitabte and at the same time it is provided to me or my representative. <br /> Nature-of_Service Request: �.� —0 t'� 1� (�•v� 't �C� Service Code •I <br /> Assigned,to Enployee Date <br /> t Wlclt T 1 k. } r y y l17 77 <br /> Y <br /> i i,DateiService Completed a '/ "` / •_`' tFurther Action Required Y=� /, N y PROGRAM ELEMENT '# <br /> a:r,•: Ov•• - ...S0.. .:.- .:..}'.a`�:'�: <br /> '.'-fJ•n ' -'Sn 'n'.�a :•�r..�.. <br /> P. r "••a:I�+• -.•tom-:iili«a.'.='.:LM1 i^•�,e n . t'1• .: <br /> s' �t'Fee.;Amountri'j ` ,t Amount Paid> sw Date'of Payaienf°, � Payment'Type ay.Receipt;t#t, Check 1 Recyd:rBy'r:, <br /> ' :. Vis• .' ;� Z. <br /> xtm <br /> Ai <br /> 15Pz: y <br /> REHS /' SUPV- '.r_ �� r/ ACCT /�"-/ -` UNIT CLK f� J r <br />