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SERVICE REQUEST (EH 00 61) Revised 8/23/93 . [FACILITY ID # RECORD ID # b INV CE # p-,#3 3 0 2J L FACILITY NAME �1.7 e Z� BILLING PARTY Y / - SITE ADDRESS �� I" 11 ,M\ S C:1 CITY /17��/J CA ZIP— OWNER/OPERATOR �ec✓s� ^-�COr�'—' �i � BILLING PARTY Y / DBA PHONE #1 ( ) ADDRESS ��`i y !/Y�L �yLel J� PHONE #2 ( ) CITY J`��7"a`'I STATE �� ZIP ��,Z 19 2 / APN # Land Use Application # F FBOS Dist Location Code CONTRACTOR and/or �► SERVICE REQUESTOR � f�/� GBILLING PARTY DBA ^�/ Wg 1 h -T PHONE MAILING ADDRESS 7i Jtf)e�e r FAX ( ) CITY �7YG�70c/I STATE (i 14 ZIP ✓1 ZD91—2 A-2Z 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 identified as the BILLING PARTY on Page 1 of this form. PAYMENT I also certify that 1 have prepared this application and that the work to be performed will be done in ac9orJance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. N O V — 4 1996 APPLICANT'S SIGNATUREYG— '— ` � LIC HEALTH SERVICES Title: g,SDate: c.� J1, a w"c^ITAL HEALTH DIVISION 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. W Nature of Service Request: JZ Service Code Assigned to �.� �/ Employee # 0-7 Date i�-/ 2 Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS / =/—( SUPV _/ / ACCT UNIT CLK _/ /