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y iY SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID #b T' INVOICE # FACILITY NAME /'1 1iiA V\, /—A/ BILLING PARTY Y / 4f r A SITE ADDRESS CITY %Yl.« //'-�• CA ZIP 9533 to OWNER/OPERATOR /YY(iCX BILLING PARTY 0 / N f DBA /Vl�l,f.� ,�a PD,('i1/�-��u.,y1 PHONE #1 (2017 ) 9143 - 02o 11 1 ADDRESS (os <_.L/I PHONE #2 (,?-o 9_) 77 - .3(p 54-3 CITY �`C1' STATE IAC ZIP 9J�2.07 APN # and Use Application # FOSist Location Code 11 1 CONTRACTOR and/or SERVICE REQUESTOR,To �a-vr .�f►� r�o �y(,� BILLING PARTY Y / DBA PHONE #1 MAILING ADDRESS �Fi �S I�IJ I FAX # ( ,ZQ / ) 4� 1 - b �3 7 i, CITY STATE_ 2IP CfJ�iZ �S a rub 2 NT � -L" n BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all 'site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party idenl`t�n d�aso the AI LLING PARTY on Page 1 of this form. APR 1993 I also certify that I have prepared this application and that the work to be performed will be done in accordikowith all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE p Title: L nt ` Date: Z/ 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 COUN'iY 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: �A-j Il X I Service Code -7-- Assigned Assigned toKjZ)-C& Employee # 3-9 :2 : Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS/ ISUPVI -/__/ ACCT _J / UNIT CLK _/_/