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SERVICE REQUEST (EH 00 61) Revisped/ ,8/23/93 FACILITY ID # RECORD ID it © INVOICE # 03.1 0 W� FACILITY NAME �� ' /"`'�- C �� BILLING PARTY Y / N SITE ADDRESS 2- 2- � 1' -�� ly /'P- _ Al CITY :- - '1'� CA ZIP J -2 . 7y��/i7 /`I� `� �-�-�- BILLING PARTY / 1� OWNER/OPERATOR �J DBA ' �� PHONE #1 ( ) ADDRESS PHONE 02 CITY STATE ZIP APN # p Land Use Application # FBOS Dist Location Code CONTRACTOR and/or I` SERVICE REQUESTOR G J� BILLING PARTY Y /� N / \ G DBA �! Yl ��}-�—� C� PHONE 012- MAILING ADDRESS �" �'t' `'� FAX # � )tX� / j J CITY � ��( �1,� �j STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END 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. 1 also certify that I have prepared this application and that the work to be performed will be done iA{dtpl�anjcey with sit SAN JOAQUIN COUNTY ordinance Codes and Standards, State and Federal taws. 1 1996 APPLICANT'S SIGNATURE �/ \ L — JRn �JcNAau JN Co ;k Title: �7 G'% �7�f//t.�e y" Date: C 2-1 DI G'/Sl0-, 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. Nature of Ser�v-ice'Request: Service Code Assigned to 1 12 Employee # L� �' �� Date Date Service Completed / / _ Further Action Required: Y / l2Y PROGRAM ELEMENT L �_ Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 15 �s b C> a/ q 6 SUPV _/ / ACCTJ, / / �� UNIT CLK _/ /