SITE INFORMATION AND CORRESPONDENCE

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♦ ♦ SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # RECORD ID # D/ 3 0 INVOICE # FACILITY NAME 0.x �G G /` r BILLING PARTY Y. / N SITE ADDRESS p CITY =LS=�=G6/.Si^ ' V CI Z I P /5 OWNER/OPERATOR BILLING PARTY Y ! N DBA PHONE 01 ( } ADDRESS PHONE #2 ( ) CITY STATE ZIP APN # Land Use Application # DOS Dist Location Code CONTRACTOR and/or � � �� BILLING PARTY / SERVICE REOUESTOR Np DBA PHONE #1 MAILING ADDRESS J (e 7 die &4A 24 FAX # ( } CITY �C �G�(i/�LD (�0��/7.V STATE ZIP ��.�1.. /D BILLING ACKNOWLEDGEMENT: 1, 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. - I also certify that I have prepared this application and that the work to be performed will W-c'QA¢ in accoocoance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and federal laws. ��J✓j APPLICANT'S SIGNATURE Title: Date: ` tk- AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sane, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirornnental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is available and at the same tian it is provided to me or my representative. �j � Nature of SerYice Request: Service Code Assigned to Employee # ,f!e.t"/J C� Date ! ! Date Service Canpleted �/_t,� / 7 Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By �`a 7 7l� REIIS / / SUPV _/ / ACCT _/ / UNIT CLK ^/ /