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0 SERVICE REQUEST 4& (EH 00 61) Revised 8/23/93 <br />FACILITY ID #RECORD ID # INVOICE # 0 <br />FACILITY NAME LG in I I g2IJe, /L T117 ���/✓� BILLING PARTY Y / N <br />SITE ADDRESS t 2 Z tj IS ES i � .1<F=o ve r? <br />CITY G b I CA ZIP Q ZI-V -Z-- <br />OWNER/OPERATOR OWNER/OPERATOR <br />DBA <br />BILLING PARTY Y / J <br />PHONE #1 ( ) - <br />ADDRESS PHONE #2 (_)_- <br />CITY <br />)- <br />CITY STATE ZIP <br />APN # Land Use Application # <br />BOS Dist Location Code IF <br />CONTRACTOR and/or <br />SERVICE REQUESTOR L4 Vel ��%� i r2ae- �1✓ [BILLING PARTY �/ N <br />PHONE #1( 9�C. ) .361 Z� <br />MAILING ADDRESS Q&qO f>C,l t2 (:2 FAX # ( ) <br />CITY _ �i%}-�I !/ STATE Ifiq ZIP CTSSSZ i <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 identifias thk,�JLLING PARTY on <br />Page 1 of this form. na� ILF r' <br />I also certify that I have prepared this application and that the work to be performed will be dorl�n6'hW a4AdJ frith all SAN <br />JOAQUIN COUNTY Ordinance es and dards, State and Federal 'kti J�JN(jUt;, <br />PUBLIC HEALTH ti; <br />wV1RONMENTAL `= <br />APPLICANT'S SIGNATURE <br />Title:��/ia�S -� Date <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 Requestf � Service Code <br />Assigned to �-1 <br />1_J Employee # -1 C _ Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS / / SUPV _/ / ACCT _J / UNIT CLK _/ / <br />