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S�fJi�G�aqG 031 _ _VI=SERVICE REQUEST/ E310FACILITY ID # RECORD ID # /Jj �CltOI CE #- a ��; � FACILITY NAME L-)1,J(3(-a L S S � � � � � BILLING PARTY Y / SITE ADDRESS CITY CA zIP C3 521 9 OWNER/OPERATOR 1 b T 2 4d✓C-^�S C.4�M P�►� �� 1:B ILLING PARTY U / N DBA U PJ C) PHONE #1 ( � 19 ) ADDRESS i�� STS -W) PHONE #2 ( ) CITY �Tl-A, STATE 6+4 zIP 9 APN # Land Use Application # I , w d b C>` QIF =BOSDist Location Code CONTRACTOR and/or SERVICE REQUESTOR T\ 0 'e p► BILLING PARTY Y / O DBA t PHONE #1 (�� to ) b3� 2 L4 }-1 U MAILING ADDRESS ZO 90 St��1��15� 6�1�Y� "-SL, FAX # ( ) CITY L Cce-CksX110- STATE <-A ZIP 7 i- 2.. BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site an-d or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifi glA#fy4PM1tING PARTY on Page 1 of this form. RECEIVIED I also certify that I have prepared this application and that the work to be performed will be done R hcor(61993h all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. sAiv JUHOuifv cOulvry I PUBLIC HEALTH SERVICES APPLICANT'S SIGNATURE 1� � t--- 1 ENViRnEDIVISION S Title: �sr� �- � Date: 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: ( Service Code ! Assigned to �le`1 i �' ads Employee # r) ' Y Date �Z/ V / Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z? l Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS / / SUPV / / ACCT UNIT CLK _/ /