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ASERVICE REQUEST r 317:31 (SERVREQ) Revised 8/2/93 rACILITY NAME / BILLING PARTY Y I If SITE ADDRESS CITY �DT CA Zip OWNFR/OPERATOR DBA ADDRESS BILLING PARTY Y / N PHONE #1 PHONE #2 ( ) CITY STATE ZIP APN # Land Use Application # BOS Dist Location Code CONTRACTOR and/or l SFRVICE REOUESTOR �O%l IJ NL7— / I BILLING PARTY X7 1Y% / N DBA PHONE #1 (S- -7_) S93 MAILING ADDRESS ��, �'�/ Ii t ),FAX `I # ( ) 10 CITY /A xy r� STATE � 21p l % JV BILLING ACKNOWLEDGEMENT: 1, 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. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE : Title: Date: AOTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 Service Request: r—lq Assigned to X-1 Ertployee If OGo � Date Service Completed —/—/ Further Action Required: Y / N Service Code D 3 I Date —/—/ PROGRAM ELEMENT Z -3. 6 D Fee Amount Amount Paid -T Payment Type FACILITY ID # RECORD ID # INVOICE # rACILITY NAME / BILLING PARTY Y I If SITE ADDRESS CITY �DT CA Zip OWNFR/OPERATOR DBA ADDRESS BILLING PARTY Y / N PHONE #1 PHONE #2 ( ) CITY STATE ZIP APN # Land Use Application # BOS Dist Location Code CONTRACTOR and/or l SFRVICE REOUESTOR �O%l IJ NL7— / I BILLING PARTY X7 1Y% / N DBA PHONE #1 (S- -7_) S93 MAILING ADDRESS ��, �'�/ Ii t ),FAX `I # ( ) 10 CITY /A xy r� STATE � 21p l % JV BILLING ACKNOWLEDGEMENT: 1, 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. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE : Title: Date: AOTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 Service Request: r—lq Assigned to X-1 Ertployee If OGo � Date Service Completed —/—/ Further Action Required: Y / N Service Code D 3 I Date —/—/ PROGRAM ELEMENT Z -3. 6 D Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By ri RENS `/ / SUPV —/ / I ACCT —/ / I UNIT CLK I_/ /