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aSERVICE REQUEST 49 CEH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # INVOICE #� <br />FACILITY NAME Lc o i i cue-,, £ �- ooyytel t BILLING PARTY Y / ON <br />SITE ADDRESS 17.2 i-".) <br />CITY �-o 0 ( CA ZIP 5Z'I-) <br />OWNER/OPERATOR �V✓Ilail �f 7 i 1�I BILLING PARTY Y / <br />DBA in Im L< �t' 4 "-? PHONE #1 (Z;2�) <br />ADDRESS I '?_2f I LiES', Lct< L7 PHONE #2 ( ) <br />CITY STATEe F'1 ZIP 52 q <br />APN IF = Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or , <br />SERVICE REQUESTOR e2u-0- U-2 r I<t =BILLINGRTY CY / N <br />DBA �yl�i �!� i.1 t t1G r t G is.1 PHONE #1 ( ) <br />MAILING ADDRESS L 1` I=t t0— 13 LV 0 irf AC; <br />j' FAX # ( ) <br />CITY C� Fes' iC: STATE CY ZIP `1 t& 7-:2 <br />BILLING ACKNOWLEDGEMENT: I, 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. p ���� <br />I also certify that I have prepared this application and that the work to be performed wiLl be done in Ro mag all SAN <br />JOAQUIN COUNTY Ordinance C9des,and St ar , State and Federal ywws? R <br />IF <br />APPLICANT'S SIGNATUR_,i/� cs /� f�� .� JUL 151996 <br />L� <br />Title: �y—IC)A�� /� Date:—'7-[S- t'� (p SAN JOAQUIN SERVICES �3CT>✓MEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent 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. <br />Nature of Service Request: A2j7�_� tiit- <br />Assigned to Fn ,C; l 1\0� ` Employee # L t l <br />Date Service Completed —/—/ Further Action Required: Y / N <br />Service Codey T <br />Date -n�—/�--�'/ I <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />P Ate <br />1 <br />=1 <br />LJ <br />RENS I / I JPV I /I ACCT I L o _ UNIT CLK I _/ /, <br />