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1 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # , R@CORD IQ 0 C' 6 ,S_/ j INV Q-1ra it <br /> FACILITY NAME W/;:Z gza � BILLING PARTY Y / 0 <br /> N J <br /> SITE ADDRESS �V / 7 �> v� <br /> CITY CQ //0 17 CA ZIP C� <br /> OWNER/OPERATOR G SC_Lr/DSI '/�/ir1/ .!///A/ 7�— BILLING PARTY Y / NO <br /> DBA f l d�� /y/ � /�'!f/ 7� PHONE #1 (_�2_04-1)a <br /> ADDRESS �� 7 f S� �2l/ PHONE #2 ( ) <br /> CITY STATE l'"i9 ZIP <br /> APN # - <br /> IFd anUse Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR J G �- BILLING PARTY Y / N <br /> DBA PHONE #1 (_,1-0 a77- 137v� <br /> .MAILING ADDRESS / Y 7CJ/ FAX # (.7 >ey )-;L,7 <br /> CITY STATE ZIP 237.,2-2, <br /> k6=� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or event of sane, acknowledge that sit 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. <br /> I also certify that I have prepared this application and that the work t9 km performed will be dean[► In accordance with att'SAN <br /> JOAOUIN COUNTY Ordinance Codes and Standards, State and Federal laws• MAR 6 1998 <br /> PPLICANT'S SIGNATURE f <br /> Title: Pate. iv7q�N.UMC S <br /> S/p� <br /> AUTHORIZATION TO RELEASE INFORNATION; In additign to the abm, %Jaen appliriaale, I, the owner, O�wratQr Or agent Of some, of <br /> the property located at the above sits oddre66 heroty iwthQrite the retsas# Of any and all results, gactschnical data and/or <br /> environmental/sits assessment infarwation t9 SAH JQACIIIN QWNTY PWIC HEALTH 66RVICE6 6NVIRQNIIENTAL HEALTH QIVIiION as soon as <br /> it is available and at the ams tine it is provided to ON ar W representative. <br /> Nature of Service Request; is i r � .C.l h service Code <br /> Assigned to W Employee # Qite / <br /> Date Service Completed / / Further Action Required: Y / N RRQGRAM ELEMENT Z, <br /> Fee Amount Amgunt Paid Date of Payment Po~t Type Raceipt 0 out Raovd Ry <br /> REHS ��� SUPV _I AGGT �,,,J / Uw.I T i<JrJt: /�,/�� <br />