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SERVICE RE9UEST (EH 00'61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID, INVOICE # <br /> P � - BdI.IING PARTY , Y. - . <br /> FACILITY NAME ` N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y. / N <br /> DBA PHONE #1 <br /> ADDRESS <br /> CITY STATE ZIP <br /> APN # Land Use.Apptication # +--�-- <br /> BOS Dist Location Code <br /> r <br /> SERVICE REQUESTQR i BILLING.PARTY / N <br /> PHONE #1 (� <br /> LA <br /> MAILING ADDRESS, - <br /> CITY STATE ZIP t t t <br /> s a� <br /> BtLLINC�ACKNOWLEDGEMENT: I,:the undersigned owner; operator or,agent of. ,'_acknowledge that all:site and/or project specific" <br /> <, , _ <br /> PHS/EHD.hourly°charges associated with this facitity or;activity will-:be: billed'to the party identified as the BILLING PARTY on <br /> Page 1 of this7. <br /> form r ;T z <br /> , <br /> I atso'certify'that I have prepared this application and the `the work ta, performed wilt be done in accordance with all SAN <br /> JOAQUYN COUNTY Ordinarice Cod 'es end: rds, State and F ral. laws <br /> 1 <br /> V .. <br /> APPLICANT°S.SIGHATURE r. <br /> h <br /> �: i r <�t r :: �':�+ .1 r3 •,`s';,D tis.. ` � �r M r - S r r' o <br /> --AUTHORIZATION,TO RELEASE INFORMATIONz In addition to the above,:when appticabte, I, the owner, operator,be, agent of same; of <br /> the property located'at the above``a to address hereby authoriae�the release of:any and all.results �geotechnical'data and/or ` <br /> environmental/site"assessment•1nformation to SAN.JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH-DIVISION as'soon as <br /> it is avaitabte and at. the some time it is provided to me or my representative. <br /> Nature.of Service Request: Service Code <br /> Assigned to Employee # ' Date <br /> y ., <br /> ;^ , Date Service Completed '�/��'/=.� 'Further ActianrRequired Y.; / N ; PROGRAM ELEMENT <br /> Fee:Amas:t Amount Paid,' Date of:Payment Y� Payment Type Raceipt'if Check # �= Recvd t <br /> i <br /> i X. Y • ACCT a s t F UNIT CLK 4 r' tb®f f t <br /> REHS <br /> �.. ., .., cv± x.,..' N:Jr:..a M.•:�v..Y••� ,.K'rr�bFt .. .K11 ..:....r I. S.t;i:.. ...>.>...,., -. _........:v. ' ..5:'...,ar.nt:.....a . <br />