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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # V RECORD ID # INVOICE # <br /> FACILITY NAME OL A/tit14�� �/ �J [` i'/��,• ��L BILLING PARTY Y / <br /> SITE ADDRESS IZ�V � /u � �/!/ <br /> CITY ��bG��19� �/�, CA ZIP <br /> OWNER/OPERATOR L)L-7A4 X1A/2 �i�� 7��� ��, � �� BILLING PARTY Y / c�l� <br /> DBA )Y�2+�cL` �S /7/ 0(J� PHONE #1 ('20 9)&Z-- g111 <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> FFAPN # – — Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTORBILLING PARTY / N <br /> DBA PHONE #1 ( n�) ( - ell <br /> MAILINGADDRESS ` ��>c /� FAX # <br /> CITY 1–�/ STATE ��' ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all 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 to be performed will be done in accl SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards State and Federal laws. 7 <br /> APPLICANT'S SIGNATURE ` C rJ nl lf` A 1nn0 <br /> Title: /– z /���� Date: –/7 / <br /> S)ACN JOAQUIN COUNTY <br /> PUBLIC ILENVIRON INENT�A�TN SE <br /> �� rN <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agenT Wte, <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. y^, <br /> Nature of Service Request: C "��� 3F �r `��� ��Ya Service Code <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment TW <br /> Receipt # Check # Recvd By <br /> ACCT _/ / _ UNIT CLK _/ / <br />